1993, 11-17 Permit App: 93011219 Plumbing Reversalq531Z
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 5-;—-12-1&,..o...4...14,0,1 �7Or
CITY: STATE: vJA50
(IF KNOWN).
PARCEL NUMBER:
ZIP CODE:
OWNER NAME: ,ZY./) aCLC'tEXVI ADDRESS: '7 ,(N -e-
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? .' YES
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*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE U
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS'''ISSUEt
CONTRACTOR: To 51 -f ADDRESS:
CITY: ''
STATE: CIA
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES� NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: /`( / / / Z j )'lf 1Vi e(Z- PHONE:
STATE:AjjH
ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE,,
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION # OF BUILDINGS X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS l X 35.00 =
APPLIC
SIGNATURE
TOTAL PERMIT FEE DUE
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SPOKANE CO TY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675