HomeMy WebLinkAbout1993, 12-15 Permit App: 93011967 Sewerg,3 1 I q6.1
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.
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JOB ADDRESS: % i- PARCEL NUMBER:
CITY: `<J/��Y STATE=GJJO. ZIP CODE: 77d�(0
OWNER NAME:
/)I/ )7 ADDRESS: >t',9 44a5',/,47A'
CITY:62 STATE: e< PHONE: A847 ---N/- V/? -
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 ISSUER..
CONTRACTOR: R S COn.S+flArhOn ADDRESS: 'kali (r. \1GL11eyvNc7
CITY: .ZPOLQGl11P STATE: vJA PHONE: Sect - 92.6. (3ci64
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STATE CONTRACTORS LICENSE NUMBER..: 45(Q1\1 lk* 123 44r
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.
SEWER CONNECTION 0 OF BUILDINGS / X 50.00 = S(%
INTERIOR PLUMBING ALTERATIONS: 0 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
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