1994, 05-04 Permit App: 94003971 Sewer 1 � G 611 `11
SEWER CONNECTION PERMIT APPLICATION FORM 7L ` , (._I .
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : X 94 S. V 04) 14\ PARCEL NUMBER:
CITY: S pO k P NJ i STATE: WP• ZIP CODE:
OWNER NAME: L I Nc (\ - �--10 ADDRESS:
CITY: 5v �r,.n. � STATE: w � ZIP CODE:
f _
PHONE NUMBER: cl -1-1 d�
PROPERTY 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: Cion .v ADDRESS : 13(a 16 . 12,0.1
CITY: -4)n�Y �P� STATE: WA- ZIP CODE: q q 2-'1
PHONE NUMBER: 9 2`1 -
STATE CONTRACTORS LICENSE NUMBER: -r-L-G G D - c 4- 101r/1G
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 = 5-0 -O O
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $ Sly • b U
APPLICANT
SIGNATURE: Co-t.t., (1/814/);-`-'(-- DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675