1993, 11-15 Permit App: 93011115 Plumbing ReversalL Fates -ST
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY: 07)%/)STATE:-�+- -
l
OWNER NAME: EVA KERNS ADDRESS 70:7( S AI/1/E,
CITY:S'��)�f+NE/ STATE: vi/rT. PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (YISCLE ONE?
702/ 5', Aiivi rk
/11
��-fIloo
ci35-log
AND IN ITS ENTIRETY
(IF KNOWN) 445-&6)A/yc,3
PARCEL NUMBER
KoG?
Mooiees SU�%L.. g S
ZIP CODE:
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 1-1-0__ CONSTZUC.TLON ADDRESS: E. CSEVo i2 AVE
ziP
CITY: S12okAf�lE LOA STATE' rnDUC PHONE: Ga1-(o-fbD
TLcco at* 1.0 704 to
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 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 # OF BUILDINGS
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
SIGNATURE ../'1(2.
APPLICANT
/
/
TOTAL PERMIT FEE DUE $ g< 00
x50.00=50.00
=35:oo
X 35.00
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675