1994, 06-14 Permit App: 94005431 Sewer 01/29/1993 00:51 509-9284306 RON SLOANq PAGE 01
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SEWER CONN ION PERMIT APPLICATION FORM qg - 5431
tTHIS APPLICATION FORK MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
rOB ADDRESS : F - / ? 9/s- t/4/6/ PARCEL NUMBER:
STATE: 6/G - ZIP CODE: G c e
►WNER NAME: AX-'1:-"C-i ADDRESS:
'ITY: STATE: ZIP CODE:
'HONE NUMBER: 9? C- ' Z Y Z
'ROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE
IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A I vJ ct\l(S A - 1' '- ADDRESS: ' ► :• iL -
ITY: c am STATE: wA Z - CODE: Qq2!--
HONE NUMBER: GI 22- 43 5 c o
TATE CONTRACTORS LICENSE NUMBER: 1 4 ,
TILITIES INSTALLERS PERMIT NUMB
NTERIOR PLUMBING ALTERATI• ? YES NO (CIRCLE ONE)
NTERIOR ALTERATION B .
DDRESS: PHONE NUMBER:
ITY: STATE: ZIP CODE:
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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 $ s-7
PPLICANT �� - /
c: \/
IGNATURE.. � - DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509)// 456-3675
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