1994, 10-13 Permit App: 94010491 Sewer C __ , .7,' ---y'
SEWER CONNECTION PERMITl'il•- 1 n't-t q 1
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:
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City: ,,_5' .? ' ` City/State: - .)cel r
Zip: ''/c2/ Zip: �1
Parcel number (if known): Phone:
T WILL THE PROPERTY OWNER BE PERFORMIN - THE SEWER CONNECTION
INSTALLATION?* Yes VNo
*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:
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Business address: Utilities installers permit number:
•
. 1(0L-o2, V6-1 Iv.{tnla•f Ave,
City/State: V el-n d�1 vjA
Zip: q q0_31 Phone: q 24 - ,5+(r35
INTERIOR PLUMBING ALTERATIONS (if applicable)**
Contr for (if different from above): Phone: "
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Business ddress: -, U .. Cit /State/Zi•¢ C'
Apr,Are„ft,
** 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,ogarage, etc., that will be connected to time sewer)
APPLICANT SIGNATURE: �v t �1 -� `� ®' Date: / ----(7 —
.40100.04.
Spokane County Division of Buildings
West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675