1993, 11-29 Permit App: 93011481 Sewer9_3 -70-1-2/
93,5 -/%
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: /O c202 / sfQ4 4040426_,4
CITY: ,b.52:4.0-ite STATE: b k,
n
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: 9902D e4
OWNER NAME: �C VY/� C��-fY n - K' ADDRESS:
CITY: (� STATE: PHONE: )a'6'-6rS t
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: k 4 5 COn-S+(urkirn ADDRESS: I lSI1 Em $IV(,IileD40,7
n
CITY: SeolrA4 STATE: 4A PHONE: Sect - c1c12462,• 4 4
Gig 2.04,..
STATE CONTRACTORS LICENSE NUMBER..: I -I'S C f7 N Yc iE 123 KF
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.
00
SEWER CONNECTION 4 OF BUILDINGS 2 X 50.00 = .'S-27-
INTERIOR
SDINTERIOR PLUMBING ALTERATIONS: 11 OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ ,S`D
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
Y