1993, 08-25 Permit App: 93007405 Sewer93 -r7
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: 2807 S. Pines RD.
CITY: Spokane
OWNER NAME: Lance Senter
(1F KNOWN)
PARCEL NUMBER:
STATE: WA ZIP CODE: 99206
ADDRESS: Same as ahnva
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: Jepson Sewer Cont, ADDRESS: s 509 Bowdish
CITY: Spokane, WA 99206 STATE: PHONE: 928-0154
STATE CONTRACTORS LICENSE NUMBER..: JEPSESH081JB
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 010 (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 =
INTERIOR PLUMBING ALTERATIONS: it OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANTErni
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SIGNATURE / �(
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SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
' REGISTERED AS PROVIDED BY LAW AS A:
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REGISTRATION
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155 o By DEPARTMENT OF LABOR ANONDUST IES