1993, 04-27 Permit App: 93002930 Sewer � . P49 9 -5 - Z33o
'3 Jaid � �� a >-
1/
, 6(2,04 so
SEWER CONNECTION PERMIT APPLICATION FORM
* IS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
TH
AND SIGNED OR PERMIT WILL NOT BE ISSU
ED .
( IF KNOWN)
JOB ADDRESS: g,
D y/ PARCEL NUMBER=
STATE= _L� - ZIP CODE=
CITY ' �� � = � -
s/ '
ADDRESS `" � y
OWNER NAME: '
.,,:N STATE
PHONE: V _ - G
CITY:5S _4,,P
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLE 0 O
T
E
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST MCONTACIS iSSHEDUTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PE
T
'f (� (gypSI Lel __ ADDRESS- E . 1381
b )2111 PAVE
CONTRACTOR NN2119
CITY= G1a1_ (o`I(p0
SPOKP�N� VVA � qQ---°—VL PHONE=
STATE CONTRACTORS LICENSE NUMBER . . : -TL-CCO 1Co1 u •
UTILITIES INSTALLERS PERMIT NUMBER=
INTERIOR PLUMBING ALTERATIONS?
413310 NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE=
ADDRESS:
STATE: ZIP CODE=
CITY=
*ONE PERMIT
REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER.
CONNECTION # OF BUILDINGS __ __
X 50 .00 = . 0._____62----b
SEWER
___/___
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS __74__ X 35 .00 = ��
TOTAL PERMIT FEE DUE $
APPLICANT �4� ,�
SIGNATURE `'
• SPOKANE COUNTY EPARTMENSPOKANET,WA 99260DINGS
( 509 )456-3675
WEST 1026 BROADWAY AVENUE