1993, 05-10 Permit App: 93003320 Sewer - 3 .,Di3 .. . .
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SEWER CONNECTION PERMIT APPLICATION FORM '(;)-
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY ,..
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AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN ) {{` I
\r 1` ) � PARCEL NUMBER= � �� 4 / �I f
JOB ADDRESS: 4LGQ7 " Q\
CITY:SptYk.fl rVE
STATE:WA_. ZIP CODE:
OWNER NAME: � C �0
� _A-S ADDRESS: `�[ z, SA/Ai) I l k+ri
R
�0 STATE: V/"A• PHONE:
CITY: �"p �
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES( CISCLE 0
NO
*IF PROPERTY OWNER INSTALLINGREQUIREMENTS BEFORE IPERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: TLC Co n1 SMI,tCTIO N ADDRESS: 6 , 1381(o )2:01 ArVE
CITY: SPOKPrNE WA
gyp. -: (*IRI to PHONE: °g21- (0`1100
STATE CONTRACTORS LICENSE NUMBER. . : -TL.CCo -W 1.01. M!'
UTILITIES INSTALLERS PERMIT NUMBER:
,z
INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . :
Ale .0
PHONE:
ADDRESS:
CITY:
STATE: ZIP CODE: —
*ONE PERMIT REQUIRED EORTEEACH
CHESEPARATE BUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECT
ER.
SEWER CONNECTION : # OF BUILDINGS X 50.00 = 0 ,b
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 = 3-S-7 ° C7
TOTAL PERMIT FEE DUE $ ' 0 0
APPLICANT
SIGNATURE // 00-tt-i--0-4,-,-'
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675