1994, 04-15 Permit App: 94003119 Sewer SEWER CONNECTION PERMIT APPLICATION FORM Cf45
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : �^ )7/ �P� PARCEL NUMBER:
STATE: [-lJ q ZIP CODE: 29c2/ 1
OWNER NAME: 7 ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE O`'
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:A4 c 5 C )r&-kADDRESS : I 18 I I I vc. I Ley v.i 1\/
CITY: L5 p0..v, ' STATE: 1n//t ZIP CODE: aQ2.bL.,
PHONE NUMBER:Eq 210
STATE CONTRACTORS LICENSE NUMBER: N'.S((Th l\I A- 41c (2.3 4
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 1 X 50. 00 = S)
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE: 7 /4,41.1.1,----ielt4‘ DATE: 47 /9
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675