1993, 04-22 Permit App: 93002799 Plumbing Reversal;-Ael° 3 — Z7(
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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.
JOB ADDRESS : ( S {..lc,
CITY:
OWNER NAME: Jnr.
(IF KNOWN)
PARCEL NUMBER:
STATE:h ZIP CODE:
ADDRESS:
CITY: STATE: PHONE: q)zk - g 7 `i�
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (44--
N�
(CIRCLE NE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: 1-1t
CITY: ^,6l(_(r�
ADDRESS:
!;t)7, C ��.)
STATE: t -c PHONE: 9 2<<9L!
STATE CONTRACTORS LICENSE NUMBER..: -/ - S CciJ
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: 1-1
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 = CC'
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS ! X 35.00 = 'S
TOTAL PERMIT FEE DUE $ S --
APPLICANT APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675