1993, 07-26 Permit App: 93006280 Sewere4_Are,14521l•1t75k
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SEWER CONNECTION PERMIT APPLICATION FORM
or3- (Pir°
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
RR (IF KNOWN)
JOB ADDRESS: 1E" PARCEL NUMBER:
CITY:
STATE : Lac ZIP CODE:
OWNER NAME : /4.0e.-0 LT ADDRESS : -
CITY: STATE: PHONE: �rZ-4,r 0153
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE NE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR : qh..s
ADDRESS: J ( Xi • Uc.tt-a-7
r
CITY:1Cbk-,%.9 STATE: LI/ PHONE: g72-6' ff562,
STATE CONTRACTORS L ICENSE NUMBER ..: 14 -.S - Cc -.i 4' x F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION WORK BY..:
NO (CIRCLE ONE)
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 = TO
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00
TOTAL PERMIT FEE DUE $ 54--)
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675