1994, 03-10 Permit App: 94001889 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN I�ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY:_STATE: Llk%
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
OWNER NAME: CL--��Gt-�<-ry C.i'�� ADDRESS: 2` IC/' ';2 2—/3���/
CITY: �S STATE: �-��� PHONE- 2cgff4- 7
PROPERTY OWNER PERFORMING.SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED -
CONTRACTOR: . o rX�d.lnMnn ADDRESS: H-402 C, \/AAkrq-Jf A4e-
CITY: \JPl`nhn6v_ STATE: WA PHONE: SOQ - L12 -4-'S �isl;
ggrJ�7.
STATE CONTRACTORS LICENSE NUMBER—: coLAR f1' -,F 1S U q
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? ESj NO (CIRCLE ONE)
INTERIOR ALTERATIONWORKBY..: 0
ADDRESS: O C� - PHONE: /:�-DSZj��
CITY: ' ��iL �-�� STATE: ' ZIP CODE: 7
*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 S
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675