1993, 04-29 Permit App: 93003044, 93003045 Sewer ey,py
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED . 45-.9 7-• l g ps-
( IF KNOWN ) _
JOB ADDRESS: �7QoZ ,,�, -p����� PARCEL NUMBER
CITY: J A/n/1/"e- STATE: (it/ASA ZIP CODE:
OWNER NAME:j -/6 /D D. A(1U/ky ADDRESS: /7o .Z S lee.-//e
CITY: if//1-/v'� STATE: �i4sf PHONE: ^-O S7f4'
PROPERTY OL'NFA 0gPFnRMING SEWER CONNECTION INSTALLATION? YES NO
( LE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? GO NO (CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : �Cd/h P 4wevei�
ADDRESS: /,7 2. -S, L//ej PHONE: `V-4 -o 5-/V
CITY: ,0,469 //E- STATE: W/95,, ZIP CODE: 974o,-/
•
*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[P-00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35.00 = 3S'"
TOTAL PERMIT FEE DUE $ 8',S. 4 D
APPLICANT
SIGNATURE 921 at-ee,_
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675