1994, 09-26 Permit App: 94009398 Sewer 0510811993 22:33 509-9284306 RON SLOAN PAGE 01
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NO BE ISSUED.
(IF KNOWN)
,Jcgra' R$ PARCEL NUMBER: _-__... ____-
�y r Z �
? : , - /2- � 2 3 STATE: hi et - ZIP CODE: 9 9 .3� ('_.�_..
OWNER NAME:A/6 !a /'Cif ADDRESS: -.--._-.----- 1
CITY: -5A--)4-49 - STATE: WA - ZIP CODE: C:
PHONE NUMBER: g 5 3 }e .
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NC
(CIRCLE ONE)
'IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. i
CONTRACTOR: A I vJ 6114 1 i v G ADDRESS: .P_Q. an. 1U-151,-,2_. `'
CITY: „5.eimpel STATE: MIQr ZIP CODE: g612l u
PHONE NUMBER: q2.2,- ®5 FAQ P
STATE CONTRACTORS LICENSE NUMBER: A LVAI AYlA O1 Q 5 __.._.____
UTILITIES INSTALLERS PERMIT NUMBER: --..-- --- *,
INTERIOR PLUMBING ALTERATIONS? YE NO (CIRCLE ONE) -Ns.
1
INTERIOR ALTERATION BY: -,
ADDRESS: PHONE NUMBER:
CITY: STATE: ZIP CODE:
'ONE PERK'. ' QUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
BE CONNECTED TO THE SEWER.
SEWER CONNECTION . # OF BUILDINGS X 50.00 = L...--"" .
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = ,_.__
TOTAL PERMIT FEE DUE $ C --
....---.1
APPLICANTq �- i
SIGNATURE: o-�-•— DATE: / ,2 �.__
SPOKANE COUNTY DEPT.. OF BUILDINGS
WEST 1026 BROADWAY AVENUID.
SPOKANE, =' ► 99260
( iMoL- 3� y- 3118