1993, 03-21 Permit App: 94002233 Sewer 3
SEWER CONNECTION' PERMIT APPLICATION FORM qy j -Zgr(
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND
SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KNOWN)
JOB ADDRESS: 15W SO • P,000.1ZE 55 PARCEL NUMBER:
CITY:
V Eazi-\-0 e.. STATE: U /- ZIP CODE: 9 cid 3 7
OWNER NAME: f47k-E-A-A) g. D P ADDRESS: SA vIA
CITY:
2.p1) STATE: (L)PrS 14 ZIP CODE: ' a3
PHONE NUMBER: c12.06 7 3 7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
CIRCLE ONE)
*IF PROPERTY OWNERINSTALLING
REQUIREMENTSMUST
BEFOREFIRST
PERMITCONTACT
ISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: LCL 00*`?5 Ac--Tt v E ADDRESS:
CITY: STATE: ZIP CODE:
PHONE NUMBER:
STATE CONTRACTORS LICENSE NUMBER:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (NO_ (CIRCLE ONE)
INTERIOR ALTERATION BY:
PHONE NUMBER:
ADDRESS:
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 BUILDINGS35 . 00
PERMIT FEE
TOTAL
E $
AIGNITUE �' /�'�` DATE: 3/ z"/ 93
SIGNATURRE:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS 456-3675
WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509)