1993, 05-17 Permit App: 93003607 SewerRin3 ri��
45a`0`,
SEWER CONNECTION PERMIT APPLICATION FORM
?�- 30-7
335-
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:54 /7/(,
PARCEL NUMBER:
(IF KNOWN)
ZIP CODE: 9041103/
CITY:STATE: i4A#
OWNER NAME:t944.1.
CITY: STA I
PROPERTY OWNER PERFORMING SEWER CO
STALL'TION? YES
(CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: A -I -WA -15 AGTAVE. ADDRESS: P a� 8.01. lq l5(9a
CITY: SroKANE VA ST TC- ggaiy PHONE: cIRD-aYz
STATE CONTRACTORS LICENSE NUMBER ..: Rt -w Ai A)it 100 P6
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:_�►
ADDRESS: '"ommomwm..., 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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675