1993, 05-17 Permit App: 93003601 Sewer 95- -NQc,
L-3 ,
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED
DSUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE
' ( IF KNOWN)
PARCEL NUMBER:
JOB ADDRESS-
STATE:1 &_ ZIP CODE: 99 4
CITY =
OWNER NAME: 41_451ML1 -4_—_—____
ADDRESS=
STATE:_______ PHONE=
CITY= -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES ‘17
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY
MUBEST FIE RST CONTACTSTHEDHE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
CONTRACTOR:
A�_WAYS i4GT= ADDRESS: —RO• $OX <<L °Z
TC: 2121 PHONE: CIRD Sr
STATE CONTRACTORS LICENSE NUMBER . . : AL4 \ `a4 "O(D P 5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE:
ADDRESS:
STATE: ZIP CODE:
CITY: '
*ONE PERMIT REQUIRED FOR EACSEPARATE BUILDING, SHOP , GARAGE, ETC
THAT WILL BE CONNECTED TO THE
SEWER CONNECTION # OF BUILDINGS X 50.00 = __________
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35.00 =
TOTAL PERMIT FEE DUE $ 511119__
A00110- -
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APPLICANT �i
SIGNATURE i AIIIII' //
r 11111111P
. ANE COUNTY DEPARTMENTOF99UILDINGS( 509 )456-3675260
WEST 1026 BROADWAY AVENUE SPOKANE,WA