1994, 10-26 Permit App: 94010702 Sewer 01/08/1992 20:42 509-9284306 RON SLOAN PAGE 01
SEWER CONNECTION PERMIT APPLICATION FORM q+- '0 qQZ
+ �2
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTITY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
ADDRESS: /05 G SIC. /3 f • PARCELONU MOWN)
CITY: SPC) .i-rvE" STATE: 1/VO4' ZIP CODE:
OWNER NAME: r"oo ( ADDRESS:
CITY: STATE: Ccs/mL- ZIP CODE: 9Q 2 0 G
PHONE NUMBER: 9/4.it -37 '
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER TREY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A I vJa.1A ADDRESS: .P.A. fr . IL.R L.2L
CITY: .40naCn./�r1 STATE: '1.4/* ZIP CODE: qQ?.�.4-
PHONE [`NUMBER: 60.2.- e 5 An
STATE CONTRACTORS LICENSE NUMBER: A LVJ j'I A A- 1067 P5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE)
INTERIOR ALTERATION BY: . •
ADDRESS: PHONE NUMBER:
CITY: .-5/4°0 AeI971.4eler STATE: . r,4 ''ZIP CODE: 9ei / /
*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 BUILDINGSX 35.00 e
TOTAL PERMIT FEE DUE $ SU
APPLICANT •
SIGNATURE: • DATE: 1° -•.� G �y
SPOKANE COUNTY:DEPT.. OP BUILDINGS
WEST 102:6 BAOADWAr AVENUE'•r -
SPOKANE,' la- 99260' A/e0�