1993, 06-17 Permit App: 93004703 Sewerc70A
SEWECONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FOR MUST BE FILLED OUT ACCURATELY AND IN ITS IRET (/AND SIGNED OR PERMIT WILL NOT BE ISSUED. +� 7-p
(IF KNOWN)
r I�s�..r PARCEL NUMBER:
JOB ADDR =•oe-
CITY:
OWNER NAME: „9I
CITY:
PROPERTY OWNER PERF
ZIP CODE:
c;7,e;„7,g2t; ADDRESS= ./
STATE: PHONE: 722 2 -9 l72,
RMING SEWER CONNECTION INSTALLATION? YES NO
(CISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: ARDISTCDN& O.ONSMUCnoN ADDRESS:
CITY: SPOKRNE, 1ADT &TTATE: ggai4
?.o. SC< iyzaz
PHONE: 428-0559
STATE CONTRACTORS LICENSE NUMBER..: AP-MSTG*�gaN1
UTILITIES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING LTERATIONS? YES
INTERIOR ALTERATIO WORK BY..:
ADDRESS:
CITY: STATE: ZIP CODE:
(CIRCLE ONE)
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 = L-11
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
$
APPLICANT
SIGNATURE
TOTAL PERMIT FEE DUE
...,ci Atifr7i51,
`�IPOKANE COUNTY DEPARTMENT OF BUILDINGS
1 WEST 1026BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675