1993, 10-19 Permit App: 93010020 Sewer45-272 flip
3 100 2.0
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.
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JOB ADDRESS: l3? c�( / A. 676c6 ,�'ic-c c PARCEL NUMBER:
CITY:.)���e/ea ar STATE: /Al{?. ZIP CODE:
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OWNER NAME: DAV?n,R ( ADDRESS: /,?cO( r C-ef / Xit" i..r- 'nirR
CITY:.S;pe, 11-A4E; PHONE: 91„og-lc--.� -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CISCLE ONE-)'
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: TLC. CDNSTeUC.T(ON ADDRESS: E. 138I(o (Z' AVE
CITY: SPC*F\ E, L)A Ggal(o PHONE: Go-21`Co-Ii7�
STATE CONTRACTORS LICENSE NUMBER..: TLCCO r*iO'7H10
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES G-17-7:- (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.
SEWER CONNECTION
# OF BUILDINGS
X 50.00 = 571 .oa
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $.50.0(2
APPLICANT
SIGNATURE.
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675