1994, 04-04 Permit App: 94002786 Plumbing Reversal 1S‘..
SEWER CONNECTION PERM•LT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
f,e (IF KNOWN)
JOB ADDRESS : //% 6 T PARCEL NUMBER: C''
CITY: 74CSTATE: �� ZIP CODE: i 9Z/7
OWNER NAME: /3A LJ C L ADDRESS:
CITY: 5/1)6' 76-- STATE: /A.,//1- ZIP CODE:
PHONE NUMBER: ?,27 �' e:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N �
(CIRCLE O
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A RACt\IS AcA V e- ADDRESS: -P.(�. y_.. la15(„2-
CITY: 6f)(--) C. STATE: WA ZIP CODE: gg2,t►-1-
PHONE NUMBER: q(1.2- Oci(O p
STATE CONTRACTORS LICENSE NUMBER: At L-. \AI A"I A - 1<t)(„ T 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALT RATrION -B AAv`w '
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 $ .3s_
APPLICANT 7— �`
SIGNATURE: ` DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675