1993, 11-12 Permit App: 93011040 Sewerhx\A.,
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SEWER CONNECTION PERMIT APPLICATION FORM
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4-35-iQo?
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
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JOB ADDRESS: /244? OJ PARCEL NUMBER:
CITY: ),-;.7 .' " STATE: `i41?' - ZIP CODE: 77&06
OWNER NAME: ' /v —i- 4I ADDRESS:
CITY: STATE: PHONE :,A%y- 9 S -C')%
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: N 4 S Co n6-1-r1,t r_ -1 -inn ADDRESS : 11.811 e , Va_i le
CITY: -;PO1LGUl2 STATE: VJA PHONE: SOG . q26. •GCA-
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STATE CONTRACTORS LICENSE NUMBER..: S C.D N 144- 12344c
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES N0 (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.
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SEWER CONNECTION # OF BUILDINGS / X 50.00 =
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
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