1993, 12-15 Permit App: 93011968 Plumbing ReversalSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
(IF KNOWN)
JOB ADDRESS: -S (S S - c r� C9 -n i PARCEL NUMBER:
CITY: STATE: ZIP CODE: 9)?,/,2<
OWNER NAME: /, . /7fL.4gP ADDRESS:
CITY: STATE: PHONE: 947/` ?/-s
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES ap
(CIRCLE 0 E)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: EE S CO rts-r(U ..Aider ADDRESS: I 1 8 11 e. \IGL.I Ie-
CITY: -5SCJOIU1Q. STATE: 1.%A PHONE: 5oci• G2,b • spc/L04-
ciciic7(00
STATE CONTRACTORS LICENSE NUMBER..: 145 CD N ¥c * 123 K
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: �Lt2 iS�i�
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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35.00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
0