1993, 06-28 Permit App: 93005252 Sewer.1
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: .2,8 e-/
(IF KNOWN)
PARCEL NUMBER:
CITY=_25;:4�e/ Ca, STATE: ZIP CODE:
OWNER NAME: Brad 577A44.00,^' ADDRESS: ,V, Z-/cF r?e>4
CITY: ,,45.�4 U/i-- 5TATE = C� c/4- PHONE: 715f 75S443
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: /7;-"k/
CITY: STATE=CZ/94 PHONE: c 2 _c
ADDRESS: Le.: /270R
STATE CONTRACTORS LICENSE NUMBER..: 727744 //S /3
UTILITIES INSTALLERS PERMIT NUMBER:
AI I --
INTERIOR
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE:
*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
SIGNATUR
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675