1994, 05-31 Permit App: 94004931 Sewer 01/1611993 02:33 509-9284306 RON SLOAN //0PAGE 01
SEWER CONNECTION PERMIT APPLICATION FORM 64 Lt-9,3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
TOB ADDRESS : e. /0114 4-7- (IFIF KNOWN)
PARCEL NUMBER:
:ITY: SfOCANE STATE: 10/4 . ZIP CODE: 9 2G (
)WNER NAME: VA 01/46 y/4ADDRESS:
:ITY: STATE: ZIP CODE:
'HONE NUMBER:
'ROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES t.
(CIRCLE ONE)
'IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
:ONTRACTOR: ,I ADDRESS: .P (�.
ITY: . p /I/1 - STATE: WA ZIP CODE: gg9A1-1-
HONE NUMBER: a, - g c n(-)
TATE CONTRACTORS LICENSE NUMBER: A L.vJ A"/A i 0 L, pg
TILITIES INSTALLERS PERMIT NUMBER:
NTERIOR PLUMBING ALTERATIONS? O (CIRCLE ONE)
NTERIOR ALTERATION BY:
)81....
DDRESS : PHONE NUMBER:
ITY: STATE: ZIP CODE:
)NE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL
3E CONNECTED TO THE SEWER.
SEWER CONNECTION • # OF BUILDINGS X 50. 00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGSX 35.00 =
TOTAL PERMIT FEE DUE $ Amp
?PLICANT 400'. .- ----- - - -- ------ --
CGNATURE: DATE: S- r/-9
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675