1994, 08-22 Permit App: 94008207 Sewer 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. q
" (IF KNOWN) (1 -UQ
2 c.
,,
JOB ADDRESS: /p2 C U PARCEL NUMBER:
CITY: STATE: G)4 - ZIP CODE:
OWNER NAME: ./Ka, ADDRESS: Af d/<>1 �CJ
CITY: , c STATE: ZIP CODE: 9
PHONE NUMBER:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N^.
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: CO\A(G1'1 LtJ' << EX c_oalai -ion ADDRESS : npt-kD2, E . Vat l,el tAral AqP�
CITY: \,e r nArAv1 STATE: IATA- ZIP CODE: q c10.37
PHONE NUMBER: q 2 A
STATE CONTRACTORS LICENSE NUMBER: CSO L 4AC.c -* 1 s 112,i
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATI ? CJYES NO (CIRCLE ONE)
INTERIOR ALTERATION BY: T� GpVt -e
0,
ADDRESS : • (1 ,0 _6; C �/ O / c PHONE NUMBER: c c /4 /
CITY: _aV(a,e- -e_J STATE: (1(,)6? ZIP CODE: 7 9 O l
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION ' # OF BUILDINGS /r X 50. 00 = tz:717Y
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35. 00 =
TOTAL PERMIT FEE DUE $ CJ
ANT
SIGNATURE:
IGNAT ! -
S I GNATURE: <;) 1 -� % �� J DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675