1993, 06-22 Permit App: 93004959 Sewer �-/ i 5,-- Li. i --
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUSTNBE FILBE LED
DDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
( IF KNOWN ) I./, ... i
Z(S L en t ���
JOB ADDRESS: ( `� PARCEL NUMBER:
CITY:
Sp oku--e_ STATE: W ZIP CODE:
OWNER NAME:
ADDRESS: - `-''''' --
CITY:
'CITY:
STATE: PHONE: i 2;--)L7xY
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (_-__;
(CISCLE ONE)
*IF PROPERTY OWNER INSTALLING
FIRST
PERMIDTNISCISSUEQ THE TILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE
ADDRESS: 11V1 Oc,,t�]I��
CONTRACTOR: 141---s141---sCITY: '')<-,1c-(----Q
STATE: PHONE: g2Co - 9
STATE CONTRACTORS LICENSE NUMBER . . : k- S -Ceti) -vX 12-310-
UTILITIES
z-3K 0UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE:
HONE: '
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 = Sb
-
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 =
TOTAL PERMIT FEE DUE $ --(.)
APPLICANT '.1--7-
SIGNATURE
7
SIGNATURE ((:2 -77 ------
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675