1993, 09-22 Permit App: 93008570 SewerQ35�� cL3- 733
33 -417 oo// cff3S -752L
SEWER CONNECTION PER'N3�� T�APk TION FiR (15-3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED. Q '� CQ1)�
Lals 1, a, 3 Q/oe-K 3 wk",G y
(IF KNOWN)
PARCEL NUMBER:
CITY: \)e ra cE QI-c STATE: w ZIP CODE: D 3 7
JOB ADDRESS :5,1-IL!0I )-I` (9,1I0a ('cdoryCY\
OWNER
NAMEcE ICY ArdsoYI *4011V,5 ADDRESS:
Wera '&00
CITY: C ) O1*6U1L STATE: MA PHONE: n� - '7 ()(
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE N
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
JL�
CONTRACTOR: LOQ -U ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES I/ NO ((_CIRCLE ONE)
INTERIOR ALTERATION WORK BY..; opi K S -PIutmb\
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: tt 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