1993, 05-03 Permit App: 93003146 Sewer 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 KNOWN )
JOB ADDRESS: /3°/-/.3/( 5 '/ --Snty PARCEL NUMBER:
CITY: %f90,6-4STATE: 4614- ZIP CODE:
OWNER NAME: Z G e/& yYa- `V.) ADDRESS:
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( YISCLE 0 )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUELQ.
CONTRACTOR: 4 6LE e=/CCw'v 7 ADDRESS: 6c7' 44.13GC.L°d-,
CITY: 57STATE: Gei/4 PHONE: 3 36
STATE CONTRACTORS LICENSE NUMBER . . : d46'6EE//a
UTILITIES INSTALLERS PERMIT NUMBER:
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 4
SPOKAN COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675