1993, 07-09 Permit App: 93005619 Sewer 64 - 5(Dict
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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: -SO4 , b /n lI vC/ PARCEL NUMBER:
J
CITY: 0/ f-/l//E1 STATE: ///4 ZIP CODE:
OWNER NAME: 4'pi►l g p A/[{ ADDRESS: S—I ( )69//17/I/UQ/
CITY:x004-Ai STATE: GilA-, PHONE: 000 - (77'
PROPERTY// OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE • •
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: TLC CONSUUCTION ADDRESS: E , 1351(o 12.* PcVE
CITY: SPOKPcNE WA -21SfiAfiE' ggo116 PHONE: q21- f0'11o0
STATE CONTRACTORS LICENSE NUMBER . . : -fL-CCO i 101 M(o
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? OYES 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 -- ,571 (97)
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS ( X 35.00 = 35 C2 O
TOTAL PERMIT FEE DUE $ X,-0C)
APPLICANT J.,1
SIGNATURE:,
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675