1994, 03-07 Permit App: 94001811 Sewer Qo 914'- I g l 1
4v SEWER CONNECTION PERMIT APPLICATION FORM t45 2 Z
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
1415 S University (IF KNOWN)
JOB ADDRESS : PARCEL NUMBER:
CITY: Spokane, STATE: WA ZIP CODE: 99706
OWNER NAME: Agnes H Campbell ADDRESS : Game
CITY: STATE: ZIP CODE:
PHONE NUMBER: Sn9-924_-4376
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO- 1
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A lv4ct\r, 4 - J . ADDRESS : .P.(").
CITY: ,4Qn.1Cl)/1- STATE: WA ZIP CODE: gg20--
PHONE NUMBER: CI2.2,- 0St()
STATE CONTRACTORS LICENSE NUMBER: A L\AI c1(A - L 6-, p 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
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 = 50 . 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $ Sn on
APPLICANT /� DATE: 7/�l��
:f�
SIGNATURE•
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675