1994, 06-01 Permit App 94004961 SewerSEWER CONNECTION PERMIT APPLICATION FORM 9 L/.--L f %
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: /Ogg/ c � t,{Y (IF KNOWN)
/w ( `Ge���9C� C�� PARCEL NUMBER:
CITY: �Of< Nr STATE: 04 ZIP CODE: 9920 Ce
OWNER NAME: `GkQe / A /22 Li7ern�
CITY: S oka/J e STATE: L-JA
PHONE NUMBER: ?a?�9 3 - O CO 6 q
ADDRESS: /Od// £ Dt,`F70iOcc1 C
ZIP CODE: ` 7." 0
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
NO
RCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: N/Gn/c/<//a £te&octl ;oA' ADDRESS: /Od// , O.^;{'l400c7 e,C
CITY: .S/007'sc<n/
STATE: ix) / - ZIP CODE: / 90?O
PHONE NUMBER: 5' S - /,5 s
STATE CONTRACTORS LICENSE NUMBER: ZN/an e o 66, Ku,c.J
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY:
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:
DATE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675