1993, 12-21 Permit App: 93012078 SewerL -I -SZ --7Z . r 032-
L L.LbSt
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT 8E ISSUED.
934zo18
935 -11 13
(IF KNOWN)
JOB ADDRESS: 5/075 ?' e S PARCEL NUMBER:
CITY: 90,1A"A-4-c-e STATE: __ ZIP CODE:
OWNER NAME: f0 /ra 4,7k/dc-/e ADDRESS `+. 13717 t i nIr n 1I4v -7.0`4"
CITY: [-`L'kft../ gqSTATEE: PHONE:
PROPERTY OWNER PERFORMING SEWS 3_
PROPERTY
YES 6;37f)
(CISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CCONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSSUED;.
CONTRACTOR: Lot;< -S /%
ADDRESS: //4/5- 7.---;,„
STATE: /-? PHONE: %30;:-5---.17e__.
(
CITY: ��n,�A-��-r'
STATE CONTRACTORS LICENSE NUMBER..: 6Co6e/ CG /$J C
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: (`%/k. 22/ " �' --s2
ADDRESS:
PHONE: 3z�r 3/
CITY: 5-7b44
STATE:lc),_-
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 = 50 CO
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
bb
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATUR
i
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675