1994, 04-21 Permit App: 94003445 SewerSEWER CONNECTION PERMIT
*THIS APPLICATION FORM MUST BE FILLED OUT
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 3?(:) -1 S. (,Q) & CU -CC
CITY : PQ l� (A 1n -oe STATE: LL)
APPLICATION FORM
a`tS ��3L
ACCURATELY AND IN ITS ENTIRETY AND
OWNER NAME: 16 I L . L RRA ,e C_ Sc v/1
CITY 3 t "c)\-dy-\ --P STATE: )3 eV
PHONE NUMBER: (1 a- a -q53 3q
(IF KNOWN)
PARCEL NUMBER: r ,,
ZIP CODE: `�l /� q
ADDRESS: 320-) S. CA C{r C( f --C
ZIP CODE: qg c,L0 �(J
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: L- 127C S+- O()5`1-( r-j-lon ADDRESS: '764, El. B([7Gtri�,JGc_
CITY:0r-)\r;Vle.-- STATE: 14,4ZIP CODE: GZQ2-12.
PHONE NUMBER: Y t I - q,GZ L. c
STATE CONTRACTORS LICENSE NUMBER:
zepi-re_.q1i 1-1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 1 X 50.00 = 5-0- 00
U
INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE:
DATE: CV/ 7/9�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675