1993, 06-18 Permit App: 93004745 Sewer 4an X64 q 3 5
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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 t SSUED .A/
( IF KNOWN ) ry�
JOB ADDR s: -5-; /-<-2Z// '� PARCEL NUMBER: `7541 •,SZO '
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CITY: .4:�/? - STATE: /g% ZIP CODE: 'Y2
[,/Cl ��%"Lr/ ADDRESS:
OWNER NAME 1,-t/f
CITY: STATE: PHONE: 922--
PROPERTY
22 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES QIP
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: flartAST12.0N&O.ON51-e-U.CnON ADDRESS: ?o. Box 14 Z8 2.
CITY: SPOKt-INE- 1A)P� ST-A�FE-: ggalq PHONE: (Ile'0559
STATE CONTRACTORS LICENSE NUMBER . . : AZrv15Tc71`9..9a N1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES N0 ( 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 i X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT �l
SIGNATURE -
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675