1994, 07-21 Permit App: 94006846 Sewer 03/07/1993 19:00 509-9284306 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:_ \Yki.) - \ SG c I . PARCEL NUMBER:
CITY: STATE: ZIP CODE:
OWNER NAME: w► 1E/1 _ ADDRESS:
CITY: STATE: ^- ZIP CODE: c:rVZ-, 1 \1
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR A Re1 Gt‘t A cah t/P- ADDRESS: -1).A).
CITY: .4Qp1C f�.e
G STATE: Id(pr ZIP CODE: g421 4-
PHONE 11NUMBER: 6117-- 13 C -o
STATE CONTRACTORS LICENSE NUMBER: A L.vJ A'I A A- 1 o Gj 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES C. (CIRCLE ONE)
INTERIOR ALTERATION
ADDRESS: PHONE NUMBER:
CITY: STATE: ' ZIP CODE:
soa-mss -asaac=� �r�„�asc=_�-s
*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 ALTERATI•NS: # OF BUILDINGS X 35.00 =
/ TOTAL PERMIT FEE DUE $ SC
1
APPLICANT /Of,"
- 1 _ Z
SIGNATURE: DATE:
SPOKANE COUNTY. DEPT.. OF BUILDINGS
WEST 1026 BROADWAY AVENUE
SPOKANE, WA 99260