1994, 09-21 Permit App: 94008577 Sewer 05/04/1993 03:47 509-9284306 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: -.. 13-57V l/' PARCEL NUMBER: -........._
CITY: f/ ,Ch ✓.. er STATE: 4.-4.4 ZIP CODE: 9 �� 00.
� /,'_,,�
OWNER NAME: `' ///5.2., y 7�f° ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (NO
(CIRCLE 6/1-E1
THE
*IF PROPERTY o�CONSTRaCT20NINSTALLING
REQUIREMENT3MUST
BEFOREFIRST
PERKITCONTACT
ISSUEDUTILITIES
DEPARTMENT F
CONTRACTOR:. A kJctv4 A t/"- ADDRESS: .i).(' . �
_ w- lU-1r�(„2-
I. STATE: ZIP CODE: G1G1?.
CITY: .4P(�1C f�►/�
PHONE NUMBER: 612.2.- 9 S n o
STATE CONTRACTORS LICENSE NUMBER: A LAPJ AI A A- tat, pg - -
UTILITIES INSTALLERS PERMIT NUMBER: --
INTERIOR PLUMBING ALTERATIONS? YES
• RCLE 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 ' ii OF BUILDINGS X 50.00 =
i INTERIOR PLUMBING ALTERATIO - : # OF BTOTDI PERMIT FEE DUE00 $ ___
AP ___ _ .-.11
APPLICANT ' c?//6) <�
SIGNATURE: . .,/- DATE:
SPOKANE COUNTY DEPT. OF BUILDINGS
NEST 1026 BROADWAY AVENUE*
SPOKANE, WA 99280 /1 CG,o
Calms�� �-- /,G,'