1994, 10-21 Permit App: 94010486 Sewer SEWER CONNECTION PERMIT APPLICATION FORM (14
I (
s
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: S J1 Z V df°^, PARCEL NUMBER:
CITY: .5/Pe)24-4/6— STATE: 0,4- ZIP CODE: 9 9Z /-Z-
OWNER
Z /zOWNER NAME: IL /C7" ADDRESS:
CITY: Si0 ZIP CODE:
PHONE NUMBER: �3 " Y 9' z—
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 4(vJaT; ADDRESS: -P.D. kw_ Ia15(-,2-
CITY: ,..-1)014(11%(.. STATE: \4/r ZIP CODE: gg20-I-
PHONE NUMBER: WV-- e 6 nn
•
STATE CONTRACTORS LICENSE NUMBER:_ A L W) /A -E' 106i f 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS. ' S NO (CIRCLE ONE)
INTERIOR ALTERATION B
ADDRESS : PHONE NUMBER:
CITY :
�, (J A4/Ve STATE: v/ • ZIP CODE: 9 r�,�" / '-/
*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
35.00
PERMIT FEE
TOTAL $ 5-0
APPLICANT jj
SIGNATURE: DATE: /'/I /9y
SPOKANE COUNTY DEPT., OF BUILDINGS
WEST 1026 BROADWAY. AVENUE.'
SPOKANE,'-WA:. 99260 `. /4 77T (�,,, 0�-