1994, 07-12 Permit App 94006480 Sewer1 A�e g�-� Alp OW, are-1-1 r�Es
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: j` 1 °2- G) 1-.-
CITY: j90 k19 STATE: l ,ti
OWNER NAME:, (� P��> -� ( n }��D_
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: / C 3 0 C�
ADDRESS: 7,_) / . -/�`e / is
CITY: vJ 1, i' Z STATE: ZIP CODE: % 9d 6 (4
PHONE NUMBER: OS) % (/(5- j
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES ( NO\
(CIRCL ONE)-
*IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
ADDRESS: r7 -C.J f t- L . 80)r,1 rl-WGl--)1
CITY: 4,I)nArA n STATE: \AJ,A ZIP CODE: q a 2.1 2
PHONE NUMBER: 2 G j -
STATE CONTRACTORS LICENSE NUMBER: Z sSr c_0 9 / - H
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION BY:
ADDRESS: PHONE NUMBER:
CITY:
CONTRACTOR: -Co()47-I--(r -con
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 = jf7 ')?)
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