1993, 09-22 Permit App: 93008681 Sewer13 = `510 c135-138
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SEWER CONNECTION PENT"QQLTION F R _ q s3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED. '� �n
L04 1, 09, 3 13/oc-K 3 Gvl1-t011-u.oW 5.y
0 �j �1 ( IF KNOWN)
JOB ADDRESS :c 1
I9 1 I I6 I I /09 1o1/Li11rNL� PARCEL NUMBER:
CITY: ��era_ct ca -e_ STATE : ZIP CODE: l V 37
OWNER NAME : � Iq .SOn Y i00VS ADDRESS : C� I 04 kea 1* o
CITY: 0 G(V1ue STATE: IAA PHONE: 5i;)5 - 19O(
PROPERTY O11111WNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FORT CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: 072u)2 IU
ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO I( -CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: I01<I S -Plumb\
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
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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