1993, 10-19 Permit App: 93010053 Sewer/V,e_c7_��
/
SEWER CONNECTION PERMIT APPLICATION FORM
'05 eq
q3 -1,0053
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: ,...57_3y_Y 4t746/----
CITY:
t7f%'
CITY:
,/144..( STATE:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: 99��
OWNER NAME: ADDRESS:
CITY: STATE: PHONE: O74
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: 14 4 S CO rt5-hr vi rfrir ' ADDRESS : 11811 e ,
CITY: Q imeja .. STATE: WA PHONE: :342>G - CI 2.6 • $G1 C,L
2.0(00
STATE CONTRACTORS LICENSE NUMBER..: 14s CDN aE -* 123 Kc
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 $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675