1993, 05-06 Permit App: 93003238 Seweru5��3.ba1c7 �`
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SEWER CONNECTION PERMIT APPLICATION
FORM
0f 3-3
35- 783
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
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CITY: -5,1474.105/c
(IF KNOWN)
PARCEL NUMBER:
STATE: W4g ZIP CODE: 7 7ga,
OWNER NAME:/e7.01 Z7Gf//L4/ ADDRESS: 7616%
CITY: S/ STATE: I
li
PROPERTY OWNER PERFORMING SEWER CONNECTION
PHONE:
9z V— 3crSr-
INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: /i/rG'/S' 47a#47/- ADDRESS: 77/7 97-
71
CITY: s/1' STATE: -4(4 PHONE: 92$6 / 87 --
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 0 (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 =
INTERIOR PLUMBING ALTERATIONS: # 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