1994, 08-31 Permit App: 94008453 Sewer cLi-- 81,3
. . .
SEWER CONNECTION PERMIT APPLICATION FORM 9/4-,,Z(41-}
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
5,/ /Z J /� (IF KNOWN)
JOB ADDRESS: / _ (/� f?/J1 rsi2PARCEL NUMBER:
CITY: .ISTATE: ' 45/24/,_. - ZIP CODE:
-', ADDRESS: %.; fG
OWNER NAME:
_ cif
CITY: STATE: ZIP CODE:
gg (/
PHONE NUMBER: / ? V` /y 7/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE 'NE
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMITT IS ISSUED.I
CONTRACTOR: J I (//4-77/ a 4 AA R 'PO �,� 237 S
CITY: ... �/ ./i STATE: Z/(4 ? ZIP CODE: 2 7
PHONE NUMBER: 7 3 f 8 9 Y/
STATE CONTRACTORS LICENSE NUMBER: (9 \/ jfV , - v 7 (7623
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YE NO (CIRCLE ONE)
INTERIOR ALTERATION BY : SW-1/1'"-F;
ADDRESS : PHONE NUMBER:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS ( X 50. 00 = 5--a)
INTERIOR PLUMB NG ALTERATIONS: # OF BUILDINGS / X 35. 00 = 3 5 ,-7ic,
TOTAL PERMI FEE DUE $ 49
APPLICANT• ,.4/''F/ * _
♦ 3
SIGNATURE: /f � DATE: rl
i
VSPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675