1994, 10-24 Permit App: 94010596 Sewer 01/06/1992 20:12 509-9284306 RON SLOAN PAGE 01
•
SEWER CONNECTION PERMIT APPLICATION FORM
*THXS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: /Q G 06 /V • PARCEL NUMBER:
CITY: ,5,1)A 4171/6-- STATE: �4 ZIP CODE: 9 Z l
OWNER NAME: Gr7 eft-
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER: ? Z V Yd ;7Z /3 Y$
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT TOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ARAI a.r4 Ac.,14v ADDRESS:
CITY: STATE: WA ZIP CODE: gg2.t t.4-
PHONE NUMBER: 4 tt- 4;5c nn
STATE CONTRACTORS LICENSE NUMBER: A l.-v4.1AN A G' p 5
UTILITIES INSTALLERS PERMIT NUMBER:,
INTERIOR PLUMBING ALTERATIONS? YES '0 (CIRCLE ONE)
INTERIOR ALTERATION BY: '
ADDRESS: ` PHONE NUMBER:
J
CITY: ,0 �e IV6 STATE: WA ' ZIP CODE: 9 /
.. ,rr.orerum=o ..mail..ammaaasoaessm
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION •6 OF BUILDINGS X 50.00 a S-`-3
INTERIOR PLUMBING ALTERATIONS:$ OF BUILDINGS____ _ X 35.00
TOTAL PERMIT FEE DUE $ �L'
APPLICANT
SIGNATURE: DATE: /oil / 9y
SPOKANE COUNTY. DEPT.. OF BUILDINGS
WEST 1026 BROADWAY'.'AAVZNUE•. •• ^ 4o#4,SPoxANE, 3A• 99260 ' A � f'
SEWER CONNECTION PERMIT Cts "! ) O
APPLICATION FORM
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 name:
/Ot .cplP E 0-44k1-- l.e
City: c_5160,KrAA City/State:
Zip: Zip:
Parcel number (if known): Phone:
WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION
INSTALLATION?* Yes No
*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:
A-I v4riy S A c i:- A L v//A /A 1_q) P
Business address: Utilities installers permit number:
Po ao II-4I5(2
City/State: .3 ()J\e. wA
Zip: 9 G 2_44 Phone: q . - B 5 no
INTERIOR PLUMBING ALTERATIONS (if 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) _ $
T•TAL FEE
(One permit required for each separate building p, ; ; ,c., that will be connected to the sewer)
APPLICANT SIGNATURE: Date: / 4
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675