1993, 08-20 Permit App: 93007297 SewerCi L C
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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.
JOB ADDRESS: 22.6 S'
CITY:
STATE: 1JN't
OWNER NAME: l 1 %tom' •
CITY: STATE:
ADDRESS:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
PHONE: (V2-6 - S 31)
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCL • ► " )
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUE0..
CONTRACTOR: PO
CITY: (54k
ADDRESS:
I/ y/7 f. UcjLQ
STATE: L}PHONE: (1 2Cs `(g`Y
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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: # 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
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DEPARTMENT OF LABOR AND INDUSTRIES
THIS CERTIFIES THAT THE PERSON NAMED HEREON IS REGISTERED AS PROVIDED BY LAW AS A
CONST (0 .NERAL •
400014;:
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