1993, 12-10 Permit App: 93011856 Sewer q3S -llco
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 .
( IF NOWN )
JOB ADDRESS: s,”?, // � PARCEL NUMBER:
CITY: 141/1 STATE: Zi)- ZIP CODE: jLD�
OWNER NAME: L.ii Ja. ../ / ADDRESS:
CITY: STATE: PHONE: %.W '(12:
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: 1445 CO CL5+1 U(,-I'ib(1 ADDRESS: H S )1 t. Vai I�J vs(a,!
CITY: „c poza 12.. STATE: VJA a�2 PHONE: Soq . q2.6 • G16�
STATE CONTRACTORS LICENSE NUMBER . . : 145 CON 4k 4- !2.3 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 04-ii) ( 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 .
a
SEWER CONNECTION # OF BUILDINGS / X 50 .00 = _5/% -
INTERIOR PLUMBING ALTERATIONS: 0 OF BUILDINGS X 35.00
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE Z//
('� ��
LI SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675