1993, 05-17 Permit App: 93003606 Sewer OLD c40,4,4-e40
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST
NBE FIBE LLED
DUOUOUT
ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERM T
( IF KNOWN )
JOB ADDRESS: �4 _ --� / PARCEL NUMBER:
CITY:
�..111111 _ STATE: ..d ZIP CODE: WWI 4
OWNER NAME: 4546.1.411.11.111PrADDRESS:
(2. ,3 Ue, v .
CITY=
-- — STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLEESS
R.,P s"�.
E
*IF PROPERTY OWNER INSTALLING SEWER, THEY
MUST FIE RST CONTACTSTHEDUTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
CONTRACTOR: fl-UJP45 ACTAVE ADDRESS: -Rip. et i 4h5(a
CITY: SPOKINNE V4N STATE= 9goZ111 PHONE: gaa-5500
STATE CONTRACTORS LICENSE NUMBER . . : Al.\rfA' i00P5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES d0 (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 $ Irto
/IF
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675