1993, 11-05 Permit App: 93010747 SewerLI0z-l.l0,0) S (ovy-7
6.0.66(_
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
SEWER CONNECTION PERMIT APPLICATION FORM
JOB ADDRESS:
1
2✓r
n
(IF KNOWN)
PARCEL NUMBER:
CITY: STATE: �C-a ZIP CODE: ?P=-2e�
OWNER NAME:
)
ADDRESS:
CITY: STATE:
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:
SSUE0..CONTRACTOR: 144S- CO (1.5+rU t1 Drl ADDRESS : I S #'1 e. x/0.11 y kAi rAy
CITY: .51001 OLI14L STATE: ./A PHONE: 5D - c12• 2 • $cf��
a�120
STATE CONTRACTORS LICENSE NUMBER..: 145 CDN 44 - 12344c
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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
cel
INTERIOR PLUMBING ALTERATIONS: ## OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 5
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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