1993, 06-08 Permit App: 93004428 Sewer G q 28
3549
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: / 90CQ S ?ICJr sJ PARCEL NUMBER
CITY: S�,„k_c.,.5, U STATE: LcN) ZIP CODE:
OWNER NAME: k)+ c k
ADDRESS: - S -
CITY=
STATE: PHONE: el Z`I -G 2.+/
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( YISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: i-4 -S- ADDRESS: W:317 3► 7 c U``R,2
-1L1
CITY: Sp ,, Ic „A STATE: (-'4. PHONE= G"-Aa`(
STATE CONTRACTORS LICENSE NUMBER . . : 1-1 --S- ( 01,J )61. 12-3K F
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 = S" -
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
RECEIVED
APPLICANT JUN 21993
SIGNATURE
INJ
CODE ENFORCEMENT
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675