1994, 02-28 Permit App: 94001559 Sewer LJ 32- 12._
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L� �3 SEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF NOWN )
JOB ADDRESS: 7C/ 9 (�✓� �-�Ce'-e�' PARCELI<NUMBER:
CITY: STATE:(/)Q - ZIP CODE:
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OWNER NAME: /46
LS ADDRESS: d ,ems
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STATE: i0 ` PHONE:
PROPERTY OWNER PERFORMING .SEWER CONNECTION INSTALLATION? YES „NO ,
( CIRCLE OBF�
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR:COuSalair Q_ 1=�C.6..ln -p ' ADDRESS: I(01402. (%, �rS.IIP ��IA4p,
CITY: Vc'( ,i - STATE: VAI ggJ3'7 •
PHONE: X09. - 6E24 -5 1---IRS
STATE CONTRACTORS LICENSE NUMBER . . : Co U1 Z f_r A4- 251 rJ
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NOy (CIRCLE ONE )
INTERIOR ALTERATION WORK BY. . :
ADDRESS: PHONE: •
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION - # OF BUILDINGS l X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT / / /2 - •
SIGNATURE . C -/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675