1993, 04-05 Permit App: 93002164 Sewer ;17.5
3s ._
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
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AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS: 12--0`l LD*.D \ v`--'S LA PARCEL NUMBER
CITY: J��' �'� '�`�' ' C) - STATE: -D'v— ZIP CODE:
OWNER NAME: ADDRESS: \ \' `L)�-'�
CITY: � � -���� STATE: Cd> Ars-- PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES C Q
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
c"'7r ��� t�r-\a`ADDRESS: Z '` Z �-- `�x
CONTRACTOR: � .�����al
CITY: ego STATE: PHONE: ck2- Lk
STATE CONTRACTORS LICENSE NUMBER . . : Ccs CSC] � ' 9 b
UTILITIES INSTALLERS PERMIT NUMBER: \S ��--
S��rt�s� / 9 a .0
INTERIOR PLUMBING ALTERATIONS? YES NO (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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT /
SIGNATURE =_ A '
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675