1993, 05-07 Permit App: 93003274 Plumbing Reversal LA,a a - (a \.}c) q -aaD 9 3- 3D-7
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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 .
��JJ ( IF KNOWN )
JOB ADDRESS: 1/021) ��
-C, /tJ /////49,96/74) PARCEL NUMBER:
CITY S �N�- STATE: LA4 . ZIP CODE:
f
W) C, 24411441
1
OWNER NAME: I�j AtirAJA.Or-IR ADDRESS: 7 -
CITY4e71) �I'/4> STATE: art, PHONE: 9.0,g6 - " 7/
YES
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLE ONE)
*IF PROPERTY OWNER INSTALGSEWER , THEY MUST REQUIREMEN7S BEFOREIRST PERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: TLC CONST2UGT10N ADDRESS: 6 ` i381(o 12"'' PcVE
?JP Ggo�211p PHONE: q21- fo'lb0
CITY: SPOI<NNE- WA ` �'
STATE CON;'RACTORS LICENSE NUMBER . . : 1L.000*ii £O.1. MID
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 41190 NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : ,33Fs��-��} i
'
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 = -522. 00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 —3.5,0e,
TOTAL PERMIT FEE DUE $ .75--,00
APPLICANT
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SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675