1993, 11-03 Permit App: 93010622 SewerN
SEWER CONNECTION PERMIT APPLICATION
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
— 3 206 �c, Docipr./
(IF KNOWNY'
PARCEL NUMBS'
CITY:STATE: \j3 NSL1 ZIP CODE:
OWNER NAME : J fC4-rt_ ADDRESS:
CITY: "--,f).D
STATE PHONE
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? VEF',
(CIR
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS 1SS%
CONTRACTOR: Q IM �t)LJ t _ ADDRESS :
CITY:�0i
STATE:IQA PHONE:
STATE CONTRACTORS LICENSE NUMBER..: —to al 51rsLLi/
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (Foi (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY: STATE:ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, E.
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION # OF BUILDINGS X 50.00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00
TOTAL PERMIT FEE DUE
APPLICANT
SIGNATURE
SPOKANE COUNTDEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVE E SPOKANE ,WA 99260 (509)456-36M