1993, 09-22 Permit App: 93008677 Sewer- (14_3;;-. g5go 93�- 73g
a3-gd77 (BS —152.
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SEWER CONNECTION PET-aa//Xt�CtttTION FR - qs3
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED. 'I
L D -r S 1, 9) 3 L3 / d e -K 3 GCJ{w�y0,c�, coociee i q t-FC(5. cRJR4ury
(IF KNOWN)
JOB ADDRESS:rS , i I�L10 0, I I jD/ I I JO2 I .PVLIU d L \ PARCEL NUMBER:
CITY: \/eracteki-e__ STATE: U) n" ZIP CODE: 61 1 q
037
OWNER NAME: ( ChOl a &)n 4114t5 ADDRESS: C-• \i 1(9-4 CI Ccua& )5 o
CITY: \. ()KanX STATE: I10Y— PHONE: n %/OC�
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..
CONTRACTOR: 3eLUQ-U ADDRESS:
CITY: STATE= PHONE
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NOS (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: I��S �" )Unt It)
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: N 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