1994, 07-28 Permit App: 94007155 Sewer qL - - 765
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: (= 7006 --71 - PARCEL NUMBER:
CITY: -7° n1-63- STATE: 1.0 Pfr ZIP CODE:
OWNER NAME: B4/4IJ C_. L/A-) ADDRESS: '70X7 /(
CITY: ,l9c'I ° STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (NO)
(CIRCLE O
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ���'� L4 ADDRESS: , %'4/- 4,01-)5 /P-
CITY: Ofit.t.-C,'YEo--),C1) STATE: /AL ZIP CODE: 9?c.)
PHONE NUMBER: 92e1 - 4 / L
STATE CONTRACTORS LICENSE NUMBER: LOA) -( -1( /4 2.4/6, "O
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: # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
-1
APPLICANT 27 (. 7s i
SIGNATURE: DATE: c
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675