1994, 09-15 Permit App: 94009002 Sewer 05/02/1993 04:32 509-9284306 RON SLOAN PAGE 01
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS : \\ 0\Z c111-1 PARCEL NUMBER:
CITY: <90kt.A \ �� STATE: ("ail" ZIP CO
OWNER NAME: f`A - w ADDRE
CITY: STATE: ZIP CODE: cl C1-• 0(,
PHONE NUMBER: Lt
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NC
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILIT.TF.S
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A I vJ c c _AG v1- ADDRESS: 1U156„2_
CITY: 5e00) �1�� STATE: WA ZIP CODE: gU211-1-
PHONE _NUMBER: C12.2..-. 1854)41
STATE CONTRACTORS LICENSE NUMBER: A L\ Ar1I A (ih 5
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 X 50.00 =
INTERIOR PLUMBING ALTERATIONS: 1 OF BUILDINGS X 35.00 m
TOTAL PERMIT FEE DUE
APPLICANT
SIGNATURE: DATE: //1/Y/7 ( '
4110
SPOKANE OUNTY DEPT.. OF BUILDINGS
WEST 1026 BROADWAY AVENUE,
SPOKANE, WA 992