1994, 03-25 Permit App: 94002449 Sewer fcd4 �z gc, SEWER CONNECT�IPrNnPE 5 CATION FORM q[45i 3 t i
fv Y
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
�'
(IF KNOWN)
JOB ADDRESS : _72/5/
72 j 5' ` � PARCEL NUMBER:
CITY: STATE: ( 7,74. ZIP CODE: e;-2'52.....2e ,‘
OWNER NAME: , - /-trGC-'2O1 ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9,;?‘ 4;
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
EIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: f-Tt +Irpnli GD(14f'(v1(ion ADDRESS : -PO. Px x_ 1142s32
CITY: Spcure. STATE: 144 ZIP CODE: etc/ 2_14
PHONE
[G2! 4
PHONE NUMBER: cr,lc . O5SQ"
STATE CONTRACTORS LICENSE NUMBER: aAM S"rGX- 1G 2-14 1-
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES c (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS : PHONE NUMBER:
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 X 50. 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $ ,
APPLICANT• �/��
SIGNATURE: :44/�� 1 DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675