1994, 10-24 Permit App: 94010588 Sewer CM3
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRED
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : S jJ Z / JLC <r4 6 PARCEL NUMBER:
CITY: jPU 2/it-/v,, /6-/ STATE: ZIP CODE:
OWNER NAME: P--/7j/. ) ADDRESS:
CITY: �"' — STATE: C-V ZIP CODE:
PHONE NUMBER: 5 V - Z /
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: 4 I vJaT, Ac.4 v e- ADDRESS: ..1)J . � I►-I- (,2,
CITY: �4er,VIA 1.0 STATE: WA ZIP CODE: go9,0-I-
PHONE NUMBER: 612-1- 1:36(c)()
STATE CONTRACTORS LICENSE NUMBER: A L.W 0V4 A 1q7(-
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS : PHONE NUMBER:
CITY: 5;) ,r/Ve- STATE: V//04 ' ZIP CODE: rde
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS X 50. 00 = S`0
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $ 5-0 --
w-
APPLICANT
0 "APPLICANT
SIGNATURE: -00 DATE: /0/ `1/r7
SPOKANE COUNTY. DEPT, OF BUILDINGS
WEST 1026 BROADWAY. AVENUE.' A
SPOKANE, fir A 99260'• /4 77T O
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