1994, 10-21 Permit App: 94010487 Sewer - - ( 1- t 014
SEWER CONNECTION PERMIT APPLICATION FORM ckL4 ,l-
*THISFILLED OUT ACCURATELY AND IN ITS ENTIRETY
APPLICATION FORM MUST BE AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : S /4,27-- PARCEL NUMBER:
CITY: 5/U2// 7V6 STATE: 1'V4 ZIP CODE:
OWNER NAME: 6- `(-2 4 /`&`cr r/ ADDRESS:
CITY: _;,/ G '-t-P STATE: Z-c-/A- ZIP CODE:
PHONE NUMBER: y .
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: A lvJalS 4[.14 i ADDRESS: -P.(). fr)Y I1-I-L56,2,
CITY: ,4,�n4C /1e_. STATE: WA ZIP CODE: cp2ALp
PHONE NUMBER: '5I Q2 — 4 rO
•
STATE CONTRACTORS LICENSE NUMBER: AO-V /k-'44% 106, Pg
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: � PHONE NUMBER:
CITY: �/ 7 C) le I✓e- STATE: V/ ' ZIP CODE: e) C../e / C"/
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION . # OF BUILDINGS X 50. 00 = -c---c/
INTERIOR PLUMBING ALTERATI,ONS: # OF BUILDINGS X 35. 00 = 3S"
TOTAL PERMIT FEE DUE $ Sj-
APPLICANT • '
S I GNATURE: /7
..• DATE: /6//7 /1
SPOKANE COUNTY DEPT.. OF BUILDINGS
WEST 102.6 BROADWAY'AVENUE - ��
SPOKANE, 99260. A 7T-: c A