1994, 04-04 Permit App: 94002708 Plumbing Reversal __ , a�-2708
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: //0 5- E / ,. !�n'VP vim'y PARCEL NUMBER:
�' U /rCODE: 9 c 0,b
CITY: 7� ! �Q �C_ STATE: co(.t.J� ZIP
OWNER NAME: �c. v 'CV c.k_ ADDRESS: v'--e --
CITY: ScP v'�^sZ
STATE: c6 �,n ZIP CODE: j�/' --
PHONE NUMBER:,teay-5 4/5-e�C)77/20e (>/4 7 37
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? - �01
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ADDRESS :
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 120 NO (CIRCLE ONE)
INTERIOR ALTERATION BY: 7 I/Ge ) i ri ?= c-
/ADDRESS : = ? O 3h->c /'f/ 2.9 PHONE NUMBER:
CITY: C'pa-Qirie___, STATE: L� ZIP CODE: 9y�/jZ
*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 = j _ ��
TOTAL PERMIT FEE DUE $ -
AM
APPLICANT �/� DATE: ' y
SIGNATURE: f��� ✓'
4;/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675