1994, 01-28 Permit App: 94000707 Plumbing Reversal • G4- ri0 7
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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 .
c ( IF KNOWN )
JOB ADDRESS : /1-7,57/7-- (c:":1141,1PARCEL NUMBER:
CITY: ? ? 1q/_ STATE: ZIP CODE: ??��1
OWNER NAME: 4a9W )/LMJ ADDRESS:
CITY: STATE: PHONE: �I -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE 'NE)
*IF PROPERTY OWNER 'INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 14 4 S CO n6-1"f U r-i-inn ADDRESS: I S )1 e. val 1 ey vdn�/
CITY: �Foleja e_. STATE: WA PHONE: 5o i - X12,6 • Vi 2-04/0
STATE CONTRACTORS LICENSE NUMBER . . : 145 ( N 44-5k 123 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YEg / NO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY. . : a-C°i�
ADDRESS: PHONE: •
CITY: STATE: . ZIP CODE:
•
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION 0E OF BUILDINGS X 50 .00
INTERIOR PLUMBING ALTERATIONS: it OF BUILDINGS / X 35.00 = �
• TOTAL PERMIT FEE DUE $ -)S�—
APPLICANT /. • - `
SIGNATURE �l ��
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675