1994, 04-13 Permit App: 94003110 Sewer r. . ql+- .3-1 10
SEWER CONNECTION PERMIT APPLICATION FORM GLtc5 . 3 ge7
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF/j��- "14 J
JOB ADDRESS: oS' �9a (/
4/ �- PARCEL NUMBER:
WN) 94c3
CITY: -7,90.J . -e-- STATE: (c/cj ZIP 'CODE: 99'e. 99, b
OWNER NAME: 41,1-uJ �f/,C�.�D/J_ ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 94:1. P,c---
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ON )
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:IA 5 C-DCt5 r- ADDRESS: 118 I '1 P, v(. I I.el vAGt
CITY: LSPc.K4f\ STATE: W,4 ZIP CODE: t J2t t
PHONE NUMBER:Eq 21e - S C( 6
STATE CONTRACTORS LICENSE NUMBER: N'S(["7I�I '� 12. -11_g
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY: -i 0>N221
ADDRESS : PHONE NUMBER:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
00
SEWER CONNECTION • # OF BUILDINGS / X 50. 00 = .�
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS ( X 35. 00 = SrO�
TOTAL PERMIT FEE DUE $
APPLICANT z://
' '
SIGNATURE: Iv DATE: 2L.,7//,C /
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675