1994, 10-21 Permit App: 94010492 Sewer SEWER CONNECTION PERMIT APPLICATION FORM 141014
*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_ /21 /4, �`�`"`-,IS v PARCEL NUMBER:
CITY: 5.12e)2� r✓E" STATE: 014,4 ZIP •CODE: Z./ Z..
OWNER NAME: � G�o�/� ADDRESS: r
"--
CITY: STATE: - ZIP CODE: -
•
PHONE NUMBER: 5-3s /c4, 6,
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: AtIv4a.1S AcA ve, ADDRESS: -P.(). NL
CITY: 3e0)//1/1". STATE: VA ZIP CODE: gq2,0-I-
PHONE NUMBER: C 22.- 1:5$ )O
•
STATE CONTRACTORS LICENSE NUMBER: A LvJ J/A - ' 106/ P5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES <_) (CIRCLE ONE)
INTERIOR ALTERATION BY: •
ADDRESS : PHONE NUMBER:
CITY: --5;1;20 of STATE: V/ ' ZIP CODE: 9 c / L/
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION . if OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT •f •
�a /�
SIGNATURE: DATE: `O/-�
SPOKANE COUNTY DEPT.. OF BUILDINGS
WEST 1026 BROADWAY.,AVENUE.'
SPOKANE, via,• 99260. ". 7-7-7 c: �.