1994, 10-11 Permit App: 94010118 Sewer 15 /11
SEWER CONNECTION PERMIT
APPLICATION FORMc' ,�
PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed,
or a permit will not be issued.
PROJECT INFORMATION
Job address: Owner's na :
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City: _ �, / / City/State: __ , '� xP /Ct
Zip: 9 / Zip: 2Q�,7/
Parcel number (if known): Phone:.
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes
*If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction
requirements before the permit is issued.
CONTRACTOR INFORMATION
Contractor (company name): State contractor license number:
H. S (.4c-Kon N S Cr - 1'2;34C.F
Business address: Utilities installers permit number:
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City/State: AS �,a{r�, I IV
Zip: q 9 2 O Phone: G 2(,, - Esc' (,-
INTERIOR PLUMBING ALTERATIONS Of applicable)**
Contractor (if different from above): Phone:
Business Address: City/State/Zip:
** For plumbing reversal fee information, see reverse side of this form.
FEE INFORMATION
Sewer Connection: Number of Buildings / X (times) $50 (per bldg) _ $ , -r—
TOTAL FEE
(One permit required for each separate building, shop,garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE: 74,4,07,/,__. 2Z,ZY Date: /�f`// 9 f
(7 inie031003
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675