1993, 10-19 Permit App: 93010047 Sewer1152,74, ocpb3 v4o4-r-cri-st- 93 1 ce7
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� 3 135 SEWER CONNECTION PERMIT APPLICATION FORM 13 l 0/
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
,
^ n (IF KNOWN)
JOB ADDRESS:�Af /,t O PARCEL NUMBER:
CITY: Sp'LDQ1/n1O. STATE: Ufa • ZIP CODE: 99..?M
OWNER NAME: in Al?
ADDRESS:
CITY: STATE: PHONE: 91-.9 9-93Cry
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: R 4 5 Coru5 YurA nn ADDRESS: 11E3M E. Vculey,,,lny
CITY: SpovLianP. STATE: VIA PHONE: SExI - {3464
STATE CONTRACTORS LICENSE NUMBER..: N'S C fl N 4E* 123 -Kr
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: W -s (14-744Z-47,2?
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ADDRESS: PHONE:
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 =
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INTERIOR PLUMBING ALTERATIONS: 0 OF BUILDINGS / X 35.00 =
TOTAL PERMIT FEE DUE
SIGNITURE l/ir �//
SIGNATURE / 4,47,/(N�45,,
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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