1993, 05-14 Permit App: 93003538 Plumbing Reversalck5.2auk. 1a
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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: - d /0 / " �� J PARCEL NUMBER:
CITY'
STATE: ZIP CODE:
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ADDRESS: - r/ 0
OWNER NAME • ��020 3 °Z_,CITY• CO
STATE:, PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CISCLE E)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: QpuRCNAINE. EIC VAT10N ADDRESS: E'_Uo3{.Oa VP' 4WAd ANV6
2.1P ggo3 PHONE: qay 5 £35CITY : VEQf}DA I -E W P. Simet•
STATE CONTRACTORS LICENSE NUMBER..: COUZCCa"iSi21
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCL��f��'�
ter
INTERIOR ALTERATION WORK BY..: � (J/'y ���/
ADDRESS:
/ 7`/O' 42)--U PHONE'! 9
4,-,I C STATE: a . ZIP CODE:
CITY:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION
# OF BUILDINGS / X 50.00 = so
= 013-6-147-15013-6-147-15INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS /
X 35.00
61-
TOTAL PERMIT FEE DUE $ ii? -s`-
APPLICANT �����,
SIGNATURE (� -
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675