1994, 02-28 Permit App: 94001560 Sewer 17AVI /c)
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i-i 481 SEWER CONNECTION PERMIT APPLICATION FORM L/- . rq q
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
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( IF KNOWN )
JOB ADDRESS: - / 'L11 � - PARCEL NUMBER:
CITY : STATE: C?_. - ZIP CODE:
OWNER NAME: -l1 fgDDRESS: r7/ :37 &1-64-6-r(21/"/"6- '1��
CITY:__ --.. ..42 :_l____ STATE: PHONE: 'c '5t," -6
/
PROPERTY OWNER PERFORMING .SEWER CONNECTION INSTALLATION? YES /NO
(CIRCLE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR:�OSSC .,n.e_ ['jCc4_.1nipn ADDRESS: I,1402 i . \fa11erlA A447.
CITY: Vc(- rt rt1 STATE: \A/A PHONE: L50ct - T24- -5L-k-RS
gG(.2<3e/ .
STATE CONTRACTORS LICENSE NUMBER . . : CO L112 fes'_46. 1 r3 4 i
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (7_;)
(CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . :
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE, ETC
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THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION # OF BUILDINGS / X 50 .00 = a �
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ d
APPLICANT /(/�
SIGNATURE --11��//� (.- '-� (QL'.�� ')
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675