1994, 10-03 Permit App: 94009709 Sewer SEWER CONNECTION PERMIT APPLICATION FORM 7`I
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED. L/
JOB ADDRESS: J��/ �'
/ �- 4J PARCEL NUMBER: `7�j /Z. „ t -3
CITY: I%
Ojd STATE: /.(lc=j'• ZIP CODE: 99a04ri 093(Y'6
OWNER NAME: 2 Ctf? AL
ADDRESS:
V
CITY: STATE: ZIP CODE:
PHONE NUMBER: ,9 ? - 7/? '
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:} 5 Co(15`I',C dcbeN1 ADDRESS: I I g 1 I r. Jci l L.lvJaY
CITY: LSP o lt_!1� STATE: WA ZIP CODE: �
QqQ1
PHONE NUMBER: q Lle - c,4 t,` -
STATE CONTRACTORS LICENSE NUMBER: I-I-. C(7/\) A- * (Z 3
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (j-9) (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.
ee
SEWER CONNECTION • # OF BUILDINGS ` X 50 . 00 = ., 1-7)--
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 . 00 =
TOTAL PERMIT FEE DUE00 $ __5"-ell--f
AIGNITUE
SIGNATURE: DATE: /_75/
Zljirri,64. _.,)1ZA09
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675