1993, 11-10 Permit App: 93010885 Sewer(T3 - /(M'
93s
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: 39ao S SupIAOU)n
(IF KNOWN)
PARCEL NUMBER:
CITY: SfQkar1 STATE: I,c)a ZIP CODE: 99x06
OWNER NAME: H YS C rycC
ADDRESS:
CITY: STATE: PHONE: 9?- S!SO
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER' INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 14 45- CO f.541 U <-4ion ADDRESS : i18)1 k . v0.314n
CITY: FKI11014j1J1 e. STATE: WA PHONE: 5D(1 . q 2b • c eq
cia2p
STATE CONTRACTORS LICENSE NUMBER..: 145 (Q f. A* 123 KK
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 = 50.00
INTERIOR PLUMBING ALTERATIONS: ## OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE $ •. or)
APPLICANT (/
SIGNATURE
:Zig)
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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