1993, 10-25 Permit App: 93010252 Sewer ()let— Orchckfas q3 -102-52.
q35 ' Rtr7
q3 -10253
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED
EOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS- O3 + , 1J it, PARCEL NUMBER:
STATE= 1ZIP CODE=
CITY��
((�� ADDRESS: 3-0-3 S ' • � � ` • . •
OWNER NAME: O^S �
i PHONE: . _
STATE: _1�5�.�=-
YES 0
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLE ONE)
E
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST MIONTACTSSHEDUTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PE 'Z� AvE
SLCNS-('(zU(-TIoN ADDRESS= E 3E
CONTRACTOR=
CITY=
4oKA1�� ISA = q--q_ a�° PHONE=
STATE CONTRACTORS LICENSE NUMBER . . : -1-LCC-07);4A-07t4 •
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 4111110 NO
(CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE=
ADDRESS=
STATE ZIP CODE:
CITY
*ONE PERMIT REQUIRED FOR EACHSEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE
ER.
SEWER CONNECTION
# OF BUILDINGS _/____ X 50 .00 =
_ 35 .00
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X = ✓
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE -40 -
SPOKANE COUNTY NEPARTMENSPOKANETWAF99260BUILDINGS
( 509 )456-3675
WEST 1026 BROADWAY AVEUE