1993, 12-30 Permit App: 93012290 Plumbing Reversal3 I fc�l7
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SEWER CONNECTION PERMIT APPLICATION
*THIS APPLICATION FORM MUST BE FILLED OUT
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: ,...V4-19�Gt�r r�1 c
FORM
93 122¢9
935 /13L/ -
93
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ACCURATELY AND IN ITS ENTIRETY
CITY: ���=�/ Le STATE:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE: 99,-Y4
OWNER NAME: --P ZLS./.91-ADDRESS:
CITY: STATE: PHONE: 7,20 -7 -39(F5 ---
PROPERTY
, 2—`7.39(F5—
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 : 4 S CO R5 -}"(u (1- rl ADDRESS: 11.81r1 vGt-11,P,y ,
CITY: ;5fxnCf.111Q.. STATE: WA PHONE: 6400c1- c12,b •
o1G20
STATE CONTRACTORS LICENSE NUMBER..: N'S C o N a4 -* 123 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 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 # OF BUILDINGS // X 50.00 =.
or
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35.00 = .33--
TOTAL
33—
TOTAL PERMIT FEE DUE $ :5 '7
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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