1993, 10-19 Permit App: 93010055 SewerSEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: ..(Ji/1/ee/.U" PARCEL NUMBER:
CITY:-(:-
' /�i4tQ_ STATE:�' ZIP CODE:
OWNER NAME: (Z/t `L)4u ADDRESS:
CITY:
STATE:
PHONE: 9/i//-/.0‘._3___?
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 ISSUE0..
CONTRACTOR: 144S- CO (1.5-}-(u <kjnn ADDRESS: I l S 11) Van
CITY: pail,0e,an.e... ‘,/./A PHONE: 500; - Cl216 • �q6�
STATE:
acj 20
STATE CONTRACTORS LICENSE NUMBER..: 15 Lo
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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
INTERIOR PLUMBING ALTERATIONS:
# OF BUILDINGS
X 50.00 = Sfi
# OF BUILDINGS X 35.00 =
avf
TOTAL PERMIT FEE DUE $ `S~a
APPLICANT -
SIGNATURE LM 2'" )
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675