1994, 06-15 Permit App: 94005721 Sewer C114.
SEWER CONNECTION PERMIT APPLICATION FORM
THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
OB ADDRESS : S 4043 Schafer PARCEL NUMBER:
ITY: Spokane STATE: WA ZIP CODE: 99206
WNER NAME : Quality Financial Service ADDRESS : 2128 Pines Rd. , Suite 17-10
ITY: Spokane STATE: WA ZIP CODE: 99206
HONE NUMBER: 509-922-3944
ROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO;
(CIRCLE E)
IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
)NTRACTOR: A[vlct\IS ADDRESS : -PS). L.
ITY: STATE: WA ZIP CODE: 2l LI-
-IONE NUMBER: c 2.2„- g S n()
['ATE CONTRACTORS LICENSE NUMBER: ,A L W A'I A 4- IP-, T 5
PILITIES INSTALLERS PERMIT NUMBER:
JTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE)
4TERIOR ALTERATION BY:
)DRESS : PHONE NUMBER:
ITY: STATE: ZIP CODE:
DNE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION . # OF BUILDINGS 1 X 50. 00 = 50. 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $ 50. 00
PPLICANT / - �'L
IGNATURE: DATE: 4 v. I S - >
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675