1994, 10-24 Permit App: 94010689 Sewer i t'i1 ' at t 1 !. F �k ,1 , 1 t ,.:A .1
1
'y �� '-1�� I ' SEWER CONNECTION PERMIT APPLICATION FORM
,i lotH S APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
A ` SIGNED OR PERMIT WILL NOT BE ISSUED.
, (IF KNOWN)
,1 JOB'ADDRESS : /t)2-fou 7 ,j 6-th PARCEL NUMBER:
CITY: SF, -a pe_. STATE: 0.)1 ZIP CODE: 999.po(,
OWNER NAME: J1 '_s")"(9 i c' 1).-. v )n Pik?-/IT ADDRESS : S
CITY: STATE: ZIP CODE: ;11)4
�' PHONE NUMBER: 9- 4 — C,370
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
JNO �i
! ` (CIRCLE oNE)
Y
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: rOFC 'S Con I k hon ADDRESS : 0111 L , 4
CITY : 4c?c?-KQl1e. STATE: vJ,A ZIP CODE : q 92)0(e,
PHONE NUMBER: q2-L4- - 6 l (at
STATE CONTRACTORS LICENSE NUMBER: F.D Q,LS c / q 4 C5
UTILITIES INSTALLERS PERMIT NUMBER: 9"T 0 336
INTERIOR PLUMBING ALTERATIONS? YES ` NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS : _ PHONE NUMBER: __ __
CITY : _ STATE• 7.1P CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS__ X 50 . 00 000
INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35 . 00 =
II TOTAL PERMIT FEE DUE $ .t9d
il—
APPLICANT
SIGNATURE: ,>! /„ � ,62,),__-4-0_1_, DATE: /� -. —rl -.
Xa
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675