1993, 07-21 Permit App: 93005898 Sewer\\I , tlaKs-rvio
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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.
� ( IF KNOWN)
JOB ADDRESS: o ��-S C/ �'� 'e PARCEL NUMBER:
STATE:‹ ZIP CODE:
CITY:
OWNER NAME: ADDRESS:
CITY: STATE: PHONE: 4;Y,21).- 3'72'
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 4(7
(YISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: I RdYiST20N& cMN5TP_LtalON ADDRESS: ?.o. Box /4282-.
CITY:
SPOKRNE. J Pr STATE: gqaiti
PHONE: 928' 0559
STATE CONTRACTORS LICENSE NUMBER..: AeMSTC*19aN1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (9 (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 = 4-4;5.
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATUR
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675