1993, 12-20 Permit App: 93012057 Plumbing Alteration7..
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: /1g4-(-
41,
CITY : ce'4444-P
OWNER NAME: ccak
STATE: 10q
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: ,Q2�/f/
ADDRESS:
CITY: STATE: PHONE: P‘z,
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR: i� S CORSE iu< Fion ADDRESS: 11611 E. \0.1Ie�1vJoj
CITY: .S�]OYf.1Jle STATE: VIA PHONE: SEx► - q2/6 • (34 L,4
STATE CONTRACTORS LICENSE NUMBER..: I4SCON )kik 123-14c
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: tli--C 0 J/G/.
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 9 OF BUILDINGS s X 50.00 =
oe
INTERIOR PLUMBING ALTERATIONS: 9 OF BUILDINGS / X 35.00 = 5� —
TOTAL PERMIT FEE DUE
APPLICANT /
SIGNATURE(/
SPOKANE COUNTY DEPARTMENT OF BUILDINGS o
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
C