1993, 05-18 Permit App: 93003648 Sewer cA3- (civi scl - "5-0(4g
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SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED
DDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE
( IF KNOWN ) ��
JOB ADDRESS: S. <4=.2 C�e/L j / PARCEL NUMBER:
CITY: e .
STATE: /L)? . ZIP CODE:
OWNER NAME: ADDRESS::
STATE: L PHONE: 9 4 e..3‘�o' — (-t t 7
CITY: �'c
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES( CISCLE • O
*IF PROPERTY OWNER INSTALLGREQUIREMENTS BEFOREFIRST
PERMITNISCISSUEDUTILITIES
DEPARTMENTFOR CONSTRUCTION
CONTRACTOR: COURNAINE. EXCAVATION ADDRESS: E - 0-1)D 2 V-114.LE4LOM 0416
ZIP ggo37 PHONE: q oty- 85
CITY: Ve2.1�DALE VI Pc � '
STATE CONTRACTORS LICENSE NUMBER . . : COu2CC*iSi R.'1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) /
INTERIOR ALTERATION WORK BY . . : ASI A�l=- -`�
ADDRESS: F- /8Y-1/g PHO :
CITY: }44e.--/l7
A ) STATE:ZAP -t ZIP CODE: 1-f:40l4;
*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 $ ff� �
•
APPLICANT JO
SIGNATURE A .
" , //
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675