1993, 11-10 Permit App: 93010883 Sewer�i3-10�3>
SEWER CONNECTION PERMIT APPLICATION FORM
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*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS : 3 S S SIA Vkel a 1A1 h
CITY:
(IF KNOWN)
PARCEL NUMBER:
STATE: Wn ZIP CODE: 99aDV,
OWNER NAME : C rx tre a 1r 1ADDRESS :
CITY: STATE : PHONE: qay -1 a eoo
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES1�0
( CIRCLE ONE )
*IF PROPERTY OWNER' INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR : N E S CO (,-libn ADDRESS : 1 t S 1'1 vU-11���(__
CITY: -5FoXCpl1le. STATE: PHONE: SY% • Cl 2A2 • Q%��
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STATE CONTRACTORS LICENSE NUMBER..: i-� 5_( f 0 f...j - 12.3 KK
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES N0 (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 It OF BUILDINGS � X 50.00 = iD,0 O
INTERIOR PLUMBING ALTERATIONS: 0 OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ 50,0 0
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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