1994, 09-27 Permit App: 94009467 Sewer 05/14/1993 21:36 509-9284306 RON SLOAN PAGE 01
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE PILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: ' / V 8P O ""1-1
(IF KN )
OWN
CITY: spoe - STATE: L�4" ZIP CODE: 'Facr/oY j-
OWNER NAME:, I- e�O £ ADDRESS: �f
CITY: ....� STATE: - _ ZIP CODE: ---='
PHONE NUMBER: c-35* 3 '`7 Z S Z
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IS PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIE£:
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A IvJal gicki u e ADDRESS: .P_Q. c)y_
CITY: A,Qc�1 A.Af. STATE:_ W4 ZIP CODE: q49 A 1-1-
PHONE 1`NUMBER: q22- 5no
STATE CONTRACTORS LICENSE NUMBER: A L MI AYA -X- 106, r 5 ___
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? (n..) NO (CIRCLE ONE)
INTERIOR ALTERATION BY: Al - 4 C.%?
ADDRESS: Y . PHONE NUMBER:_._,
CITY: J I' 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 $ p S-
APPLICANT 2.11111111111111111° ?4 ;7 /16:11// Lj -
SIGNATURE � -- - DATE: / ////Z
_ C
SPOKANE COUNTY DEPT.. OF BUILDINGS
WEST 1026 BROADWAY. AVENUB
SPOKANE, 'WA 99260