1993, 05-18 Permit App: 93003630 Plumbing Reversal 1D s `--a 0 S ' ,' 9 -'- (073 9 3~3(0 0
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLEDOUTACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE
( IF KNOWN ) �---T
JOB ADDRESS: 4,57
ca/ LJ le% PARCEL NUMBER:
CITY: A --
STATE: _a3 - ZIP CODE
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OWNER NAME: ADDRESS: ,� /���
CITY: C'�
STATE:(-00' - PHONE: ,alc��
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES •NO `
( CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST
FIRS
THE
DEPARTMENT FORCONSTRUCTION UCTION REQUIREMENTS BEFORE PERMIT IS ISSUED
CONTRACTOR: Re���NE EXCAVi�TioN ADDRESS: E - ltoliO VpLLE'W m p.svE
2AP
c ? ___ PHONE: °�4 5 .BMJ
CITY: yr g±4LI SLE W Pt
STATE CONTRACTORS LICENSE NUMBER . . :
CouQcC4k x.81 R-`i
UTILITIES INSTALLERS PERMIT NUMBER:
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INTERIOR PLUMBING ALTERATIONS? 40 NO (C RCLE ONE)
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INTERIOR ALTERATION WORK BY . . : / % 10,./i_-_,'
d - % / PHONE: 9,2...Q--/ 5i//
ADDRESS: 2F', � , Q
� 1... ,.../ O /�
CITY: /1 . /l ��[ ST ATE:J�.�-�-= (�
ZIP CODE: % `
*ONE PERMIT REQUIRED FOR EACH
CHESEPARATE BUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECTED TO
SEWER CONNECTION # OF BUILDINGS I X 50 .00 =
—�
X 35 .00 � c 7���
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS `d4D
J
TOTAL PERMIT FEE DUE $
APPLICANT / - . �/ r
SIGNATURE . e -' 1�-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675