1994, 03-25 Permit App: 94002446 Sewer CL4
qYn '"SEWER CONNECTION PERMIT APPLICATION FORM
LI, tiVONfC-65-1-
*THIS APPL CATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUE ED.
(IF KNOWN)
JOB ADDRESS : /9 C0,4r-- / , /�l" PARCEL NUMBER:
STATE: 2 ZIP CODE: 9'9'-2/4
OWNER NAME: - 'L�r " tare c: ' �l ` ADDRESS: JUS co `"11. ,r p 17"J
CITY: STATE: ZIP CODE: 49e/' •%�.1e"-
PHONE NUMBER: 7 c2" 7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE 0, )
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A(n5-hrDn11 CDn •f-(w(-1- p,n ADDRESS : 4) 0. Pc,c. I4Z,F32.
CITY: Apq1w_ STATE: VJ4- ZIP CODE: e{a2! L-4-
PHONE NUMBER: Cr 055 q"
STATE CONTRACTORS LICENSE NUMBER: AAM G c 1 G Z,t.J .1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES e5) (CIRCLE 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 . # OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 =
TOTAL PERMIT FEE DUE $
APPLICANT J /
S I GNATURE. k � � DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675