1994, 04-18 Permit App: 94003253 Sewer 1CA - OK'o PP12 S,rn iN UT/urfe5 (71-1 ZS3
SEWER CONNECTION PI RMIT APPLICATION FORM 61415 • (4OV
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN) C14-32.6-4-
p4 3 2.6-4'
JOB ADDRESS:LII a0& /$ PARCEL NUMBER: ``II
CITY: - / / / STATE: /�4. ZIP CODE:
•
OWNER NAME: ; ADDRESS:
CITY:
STATE: ZIP CODE: q,Aq
PHONE NUMBER: _11.3i-01/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YE
ES
(CIRCLE 0 N)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR:_I 5 COI15±:c..A.C.A1C>n ADDRESS: 11811 _ \J(1 I I l` ri
CITY: L.Sp(7./t!1?� STATE: WA ZIP CODE: QG[2bb,
PHONE NUMBER: 6i210 - r3 c16'4
STATE CONTRACTORS LICENSE NUMBER: I-FS((-) • 12-3 - -�
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? ® NO (CIRCLE ONE)
INTERIOR ALTERATION BY: 97/ �-�
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
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35. 00 =
TOTAL PERMIT FEE DUE $ �5
APPLICANT �l� i� DATE: j /�`P7
SIGNATURE: -,4'�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675