1993, 11-10 Permit App: 93010882 Sewer(q--5 9V -s
SEWER CONNECTION PERMIT APPLICATION FORM
KTHIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: S, 3(Fi 3(F 08 SU v1 AODO r1
CITY: S okn n.e_ STATE: WGL. ZIP CODE: 9'97,206
1
OWNER NAME: S u. S /4 nl S c k n' , J t ADDRESS:
CITY: STATE: PHONE: 9 - a 5 9 S
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (NO)
(CIRCLE ONE)
a
(IF KNOWN)
PARCEL NUMBER:
*IF PROPERTY OWNER' INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: k S CO R.S-I'(u (-hon ADDRESS: ii.f311 e . \)W le_Ni v4 y
CITY: -6FOLL&GUIe. STATE: 1JA aGPHONE: Soq - G2.b • pQ�a4
2
STATE CONTRACTORS LICENSE NUMBER..: i -%S CDN 44-* 123 K
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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 = 5O.0o
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 50.00
APPLICANT
SIGNATURE.
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
a