1993, 04-22 Permit App: 93002842 Sewer \qcrbn
( (25,5
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS: 5' 0 (� 0e v CZ` PARCEL NUMBER:n.!
CITY : 5
pc, STATE: L✓� ZIP CODE:
l
r� aW w �c7c, ✓ ADDRESS: 5 ��v
OWNER NAME: 1� //y
CITY: :2 c3�/lAv—e..
STATE: A PHONE: 9 &- 33 /7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 65)
(CISCLE ONE )
U
*IF PROPERTY OWNER INGSEWER , THEY MUST FRST REQUIREMENTS BEFORE:�IPERMIOTNISCT THE ISSUEQ TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR:
(;.3P- 5 ADDRESS: d //2/S 4-
CITY:
-CITY: ��4.4
STATE: PHONE: CZ y" S 3 2 2
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE.)
INTERIOR ALTERATION WORK BY . . :
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*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 $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675