1993, 04-27 Permit App: 93002933 Plumbing Reversal aao .. C� - -O9 32
" 2
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE
FILLED
DUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOTBE
)7/7,4k0-72-..,-- ( IF KNOWN )
JOB ADDRESS: 5 2 () S. 1f,4ii 1� PARCEL NUMBER:
STATE: AL_ ZIP CODE:
CITY:- 7$49z94VAii
/2 /0 ��O S ""/v A4
OWNER NAME: �� / ADDRESS:
CITY:� Q �s
c) /✓E" STATE: 11)4 PHONE: 9.,.. <C23-- O /
P
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
ERCLE 0 NO
(CIRCLE
*IF PROPERTY OWNER INSTALLING EQUIREMENTS BEFORE,
IPERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION R
CONTRACTOR: TLC Co N SULICTI0 N ADDRESS: 6 . 15£31(r) )2 PcVE
CITY: sQOKPtNI✓ WA
� : c1.9 Ito PHONE: gotl' fo'llo0
STATE CONTRACTORS LICENSE NUMBER. . : 000AkiE 1.01 M('
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : 29-1e-S±CA.)19/
PHONE: '
ADDRESS:
CITY: '
STATE: ZIP CODE:
*ONE PERMIT REQUIRED
FOR
TEACH
HESEPARATE
BUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECTED
SEWER CONNECTION # OF BUILDINGS ( X 50.00 = ,,,SI •QL
. ST- C)0
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = TU
TOTAL PERMIT FEE DUE $ S
APPLICANT �
SIGNATURE
CtsLettyLi.j..:
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675