1993, 10-18 Permit App: 93009878 Plumbing ReversalOrp 51.1,197r' 1z-)
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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.
/�// �e/y/� (IF KNOWN)
JOB ADDRESS:
Cl //, "1 S - - PARCEL NUMBER:
STATE:L-r ZIP CODE:
CITY-
OWNER NAME: 4/1 2:5 LZ..) ADDRESS: •.,36 q /0/nea-/6'O�`
!L�
CITY:
7j /(i
STATE: L.e PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
NO
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: CouRCNAINE. EXCAVRTION ADDRESS: E - lb4.Oa U14L(.EY WRd 1 %qE
21P ggo37 PHONE q2(4-5 85
city: Ver2),DA;LE \A N
5 i HT"c LVI! 1 Kr.CTC^L .rTr•GA1gF NUMBER..:.. .
Couzcca" isi a1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? (tel
N WORK BY..:16
// ` 1
NO
(CIRCLE ONE)
INTERIOR ALTERATIIO /- /• •• . - l -75
/ Y7Q �(70 C� - re_e_A-2i PHONE: -
ADDRESS: U // �� 9-29'� /'"CITYa `�
�� �� STATE: GC/a 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 $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675