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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