1993, 05-27 Permit App: 93004042 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
/�� � (IF KNOWN)
JOB ADDRESS: 408 " 6 /D S. l`P/XLG/l PARCEL NUMBER:
CITY: PZirrii�/ STATE: (O4 • ZIP CODE: 9-IOct7
�
OWNER NAME. �¢araA 717tie(a,DDRESS: alS D6o 5, ��l
J
CITY: Qie JC -STATE: WC PHONE : ,55:6--- 6a-69—`
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? VE
(CIRCLE ON
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
Qs
CONTRACTOR / /t)V=S ADDRESS: C // /
STATE: CUA • PHONE: 9;1471-8fl/
CITY:
STATE CONTRACTORS LICENSE NUMBER..
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT f v) n// t
SIGNATURE d �Ga� X��C!(�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026. BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675