1993, 10-18 Permit App: 93009875 Sewer°\354 (03 6“57
q3— 5875
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.
//,// ( IF KNOWN)
j %kso 9 /J 4I0�-yC(�L'-eCY , PARCEL NUMBER:
JOB ADDRESS: /r/ ”
STATE: (pja
- ZIP CODE:
CITY:
OWNER NAME:
CITY: ‘,5,7-- " a STATE: 404: ,
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (YES
ISCLE
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: COaRCHAINE El(CAVftTION ADDRESS: E.IIoitOoi UM1E414M NIG
CITY: \fE2.p.DALE
?ATE- ggO37 PHONE: qty_ 5485
a co
ADDRESS:
2 Me -v d
PHONE.: __-- --3/436 7
�..nco C.OU.2CCm.±81R-�1,._
STATE CONTRACYOrtS LICENSE IW ivy" • -
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY:
(CIRCLE ONE)
STATE:
PHONE:
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 $ .Tic
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675