1994, 10-25 Permit App: 94010649 Sewer 46„,
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,v1,401---‘' ‘ (, SEWER CONNECTION PERMIT
VI 2Z I ATION FORM
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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
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Job address: Owner's na e:
994 /'4.di! "
City:\�J City/State: /i 1 ,0 ZJa Zip: 99 7 Zi p: 99
Parcel number (if known): Phone:
WILL THE PROPERTY OWNER BE PERFORMJNG 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:
14 S Conc-I-,r(Ac - ,r\ NSCrW * *- 12:2)4l.F
Business address: Utilities installers permit number:
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City/State: ,S c:). (AA
Zip: q G 2 0 Phone: G 2,i, - S G ce,L4
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) _ $
TOTAL FEE
(One permit required for each separate building, shop,garage, etc., that will be connected to the sewer)
APPLICANT SIGNATURE:
Date: /� �S`
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Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675