1994, 02-14 Permit App 94001129 Sewer453a .otoz
,PQrv- a�
b? R (
G1,5.1,0
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:/)
CITY : 6PO Rat h '-e
OWNER NA
ME: : l � (0 I 1 `P r--F fi v frffitn n ADDRESS: C/ to / ` ' . "ter 1-r-fb.30,q
�l
CITY: 0/10 --Q STATE: Oa PHONE: `7
PROPERTY OWNER PERFORMING SEWER CONNECTION,INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMITNISCT THE ISSUED_.TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: 2. 6eAk ,n tVV*2(' ADDRESS: 1S1 Briadvlcti
CITY: .40pI4,Qi STATE: W4 PHONE: B I l - cta L0
4g242
STATE CONTRACTORS LICENSE NUMBER..:
STATE: L )
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
(CIRCLE ONE)
STATE:
ZIP 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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675