1993, 10-29 Permit App: 93010479 Sewer145374. < <07
SEWER CONNECTION PERMIT APPLICATION FORM
435
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS:
CITY :
(IF KNOWN)
PARCEL NUMBER:
STATE: //Oa . ZIP CODE: 99�G74
OWNER NAME: 1;,/,H.,:14-,' ��. ADDRESS:
CITY: STATE: PHONE: 9.96/-,_39s1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 0
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER..
CONTRACTOR: S CO (1.5+(U (s- C'I ADDRESS: I1 E . vOU 1el��(,_
CITY: -6pOSCpl112. STATE: vJA PHONE: SOG - q2.r►(o • $//G(o�-�
�-1ci20
STATE CONTRACTORS LICENSE NUMBER..: N'S"< f7 N 44 4. 123 KK
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 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 1 X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ .5D
D
APPLICANT f
SIGNATURE Lam' / -17)7,71e
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675