1994, 02-22 Permit App: 94001368 SewerGig-- ,0?
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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.
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SS : r16 Z0 5 . 00AR Z,A. PARCEL NUMBER:
Wk CITY=Je'b�
V)W STATE: k ZIP CODE:
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OWNER NAME t M l LiNtiK) ADDRESS: kOD W
CITY CKVAJ STATE:, Wfk PHONE: c/ WA -C�5
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PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? CES 42)
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*IF PROPERTY OWNER
CONSTRUCTIONINSTALLING
REQUIREMENTS BEFOREFIRST
PERMITCONTACT
UTILITIES
DEPARTMENT FOR ISSUED
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CONTRACTOR: SLC- CONSTeUCT(ON ADDRESS:
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CITY: SPc= K A ( l. D A STATE -r.
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STATE CONTRACTORS LICENSE NUMBER ..: n -Cl �'t4 A -01-/M (,2
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 1 X 50.00 = 6"b,D
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT }31
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675