1994, 05-23 Permit App: 94004633 Sewer N 1 1 \
SEWER CONNECTION PERMIT APPLICATION FORM Q`15 -C i
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : /OS (67/ 1/�r_-,,'1� (IF LOWN)
� � � f PARCEFL NUMBER: �!-��7:3 '-q�' r S
CITY: � \c-/rC l) STATE: I U/c-L, ZIP CODE: 9 -c
OWNER NAME: !)9L 1. /3CcADDRESS : S //c'-SJ /67, (10-07
CITY: .Sfk STATE: � � - ZIP CODE: 79dc-i4
PHONE NUMBER: ( 9/ - 6 2
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: -174`� iZ ' L�(�. �"i�%'C '4 ADDRESS : /1/. /77„..? 3 772:1(.1/-50X/
CITY: IL%A STATE: C�C`� . ZIP CODE: J �'�
PHONE NUMBER: C`5 Lam/ ifs - L/"i ?
STATE CONTRACTORS LICENSE NUMBER: 7—A-LiL_c' t 4( /60 4-'7--
UTILITIES
-'%UTILITIES INSTALLERS PERMIT NUMBER: -- /q3
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION BY: c:24/(J /R 6-c"YC
ADDRESS: , //r$ _ i'//f/s- /1/7 PHONE NUMBER: 3)-9/ - 7 2 2
CITY: sip67-0/ STATE: kik ZIP CODE: j ,_)e-,<. 7
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: 74/J'A ti?
• iL • '/ DATE: c l
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675
REGISTERED AS PROVIDED BY LAW AS A:
3a
CONST CONI GE N E E L
REGISTRATION EXPIRATION DATE
NUMBER:
0-01 A.YLOE11,001(T 06/02/94
EFFICTIVL DOE 05/30/90
. �AYII?R' SEXCA015E}NT��G
N 17923 A 99021
MwpD
•
SIGNATURE 41, -44-4i INDUSTRIES
ISSUED t) DEPAR'I1 ENT OF LABOR A '
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