1993, 08-20 Permit App: 93007249 Sewerc -2 `E` N.
7
6 -
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLEDOUTACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS:
76) t5 ir-4,6 /4jO PARCEL NUMBER:
CITY : 57jPD A-AAJ/Ft
STATE: ZIP CODE:
OWNER NAME: E�� (
/ /� i✓i�4 ADDRESS: 1 7� ��-
��i
CITY :J C%/ /Vrj STATE: A/T'.
PHONE: /, -33_6 6
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CISCLE 0
*IF PROPERTY OWNER INSTALLING SEWERUIREMENTS BEFORE,
IPERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION R
CONTRACTOR: TLC CO N STe(,tCT10 N ADDRESS: 6 130t0 12°1 °1 /WE
CITY: SPON
KPcE- 1�1A _
�- gcIR 110 PHONE : q21" (0-110
STATE CONTRACTORS LICENSE NUMBER..: 71.-CCO*iE 101 Mlo
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:,t6r-Sted#7/
ADDRESS:
CITY:
STATE:
PHONE:
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION
INTERIOR PLUMBING ALTERATIONS:
# OF BUILDINGS
# OF BUILDINGS X 35.00 =3,5.00
TOTAL PERMIT FEE DUE $
e 0�
X 50.00 = �j
APPLICANT
SIGNATUREC-A?tkAA-A110"
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
L 1____
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