1994, 06-08 Permit App: 94005216 Sewer'N' PooDe-e-DS og5-(613-1
SEWER CONNECTION PERMIT APPLICATION FORM 9(1-- 5 a 10
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
/ (IF KNOWN)
JOB ADDRESS: . S --,Q. ,()S 7.�.%i( PARCEL NUMBER:
CITY: � 2- ',-Le_ S ATE: //q r ZIP CODE: 9;7/M/
OWNER NAME: jAdIA ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: 9,?o? ` 7 9j/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
/
CIRCLE O )
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: “ 5 CDf15-t Lu C -F, C}f1 ADDRESS: 1 1 8 1 '1 I.
CITY: LsIeO.tif ./ STATE: WA ZIP CODE: Qq2. f7(r,
PHONE NUMBER: Cl 2- - f q
STATE CONTRACTORS LICENSE NUMBER: i -F". C (7&) zic 2_ 3 -ki
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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:
.0.1??
DATE : *Y7/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675