1993, 12-10 Permit App: 93011853 Sewerq35 -13'n
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.
JOB ADDRESS:
CITY:
STATE:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: MW
OWNER NAME: �/}/J y % ADDRESS:
CITY: STATE: PHONE: 9a71'-/�S S--
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES Ai-CP
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER..
i
CONTRACTOR: 14 4 S CO (166-1"(u 14- Lt- ADDRESS : 11811 t . \IGH 1 L_
CITY: -6fO(t9Jl2. STATE: VSA PHONE: 5001 - (1 lb - 3G��
aq
2.04,
STATE CONTRACTORS LICENSE NUMBER..: 146 CDN a4 123 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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
X 50.00 = S%,
INTERIOR PLUMBING ALTERATIONS: ## OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ ,_%
6"Y-
APPLICANT
Y
APPLICANT
SIGNATURE
_ (2V,,Z7-72/:-Le,
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
0