1994, 03-04 Permit App: 94001713 Sewer 5z13 .a - I3
01,4 ash
SEWER CONNECTION PERMIT APPLICATION FORM IGS Z 3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
Fa(KNOWN)
JOB ADDRESS : //063 J/OOS of 7 - PARCEL NUMBER:
CITY:,SP()k in STATE: ) A ZIP CODE: RC(00(
OWNER NAME: 3 r- War r ADDRESS : /0 /0 E
CITY: 5 pO k/.F h . STATE: (A ) ZIP CODE: 9*R b(e)
PHONE NUMBER: 41 -_-9/D qf q` 36,-;)
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO i'
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: Z ' c s+ co o,S4{u r-1-1011 ADDRESS: '7 El 8r-on rivJet.. /
CITY: .,pr>.Krk STATE: N/A ZIP CODE: qq ZI ?.
PHONE NUMBER: G I - q,q LL c
STATE CONTRACTORS LICENSE NUMBER: Z - 099 -A1-1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 10� (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 f X 50 . 00 = SO.00
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT
/\/OL4lO7t)SIGNATURE:
DATE: -3 - Cl 711
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675