1993, 10-14 Permit App: 93009781 Sewer SEWER CONNECTION PERMIT APPLICATION FORM j
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
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( IF KNOWN )
JOB ADDRESS: „) o� / S. )/NNIAA PARCEL NUMBER:
CITY: 1. ► k ► " STATE: 1A,A , ZIP CODE:
OWNER NAME: f1 A) Pr5i E; ADDRESS: � oZ 4- S 1� i zw d
L� 11 yI
CITY:. ,.)a) STATE: tA)A - PHONE: 9,24 - L444 P"
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE 0
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED,.
CONTRACTOR:—/-- r , CNS ' ADDRESS: 42E J )Q1-"A
CITY: � A�I E STATE: 1./14- PHONE: 9027- 6:27 p
STATE CONTRACTORS LICENSE NUMBER . . :
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
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THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION - # OF BUILDINGS ( X 50 .00 = � l7 d
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35 .00 = 3 5,0 0
TOTAL PERMIT FEE DUE $ `' C, C)
APPLICANT -
SIGNATURFF
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675