1993, 09-14 Permit App: 93008268 Sewer .' . q3 - 8aa8
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 .
h ( IF KNOWN )
JOB ADDRESS: / ;7(27 cQ S,, /6-2,4tR PARCEL NUMBER:
CITY : STATE: 0/) , ZIP CODE:
I
OWNER NAME: I v` u �= 1 ADDRESS: ( 7O SCP ,
A<E_Li_f:R
CITY=, N STATE: < '
PHONE: 9 - 05
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CISCLE ONE
*IF PROPERTY OWNER
CONSTRUCTIONINSTALLING
REQUIREMENTS BEFOREFIRST
PERMITCONTACT
UTILITIES
DEPARTMENT FOR ISSUED
CONTRACTOR: TLC CoNsTP--UCTioN ADDRESS: E ` 3S1(o I2EWE
"LP
CITY: SQoKPtN& gcia l(o PHONE: ciOZ1" Collo()
WA
STATE CONTRACTORS LICENSE NUMBER . . : �t�CCO �k .01 M60
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
OF) ( 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 = -50, 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE r
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
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