1993, 07-08 Permit App: 93005589 Sewer 6 - SSg�
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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 . 13�K-���
5�I . 014o S /l/4/—/� ,�,Pn���SS
D2t I , ,�s� ( IF KNOWN )
JOB AbDRESS: -S 1 602 x — � PARCEL NUMBER:
CITY : STATE: (API)/ ZIP CODE: 7 92Z6
OWNER
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OWNER NAME:_
r) : 611C 77 -,5- ADDRESS: S / /‘
CITY:
CITY: � '
.e STATE: wA/ PHONE: iia 7 _ 7 �
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ,0 NO
(�'CLE ONE)
*IF PROPERTY OWNER ISEWER , THEY MUST NSTALLING
BEFOREIRST PERMIOTNISCT THE ISSUEQ TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: ' � �� ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 41110 (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