1993, 06-16 Permit App: 93004626 Sewer J N.
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SEWER CONNECTION PERMIT APPLICATION FORM `(3 S - Li-Q 3
*THIS APPLICATION FORM MUST BE FILLED
DUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE
( IF KNOWN)
� 3 PARCEL NUMBER:__
JOB ADDRESS' ��AA
CITY:
. STATE: Gi)a` ZIP CODE:______
OWNER NAME: / -(- - ADDRESS:
CITY: o..7a3,9c0 -
STATE: PHONE: ___ — O 6 o
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 611-0
(CISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY
MUST FIERST COONTACT ISTHED HE TILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
CONTRACTOR: RCNAi NE EXCRVP�TION- ADDRESS: -ADDRESS:___ El&AM IN`YG
2 P gg037 PHONE: q a4- �34E
CITY: vr�Q„ptD PslTc W Pt J
STATE CONTRACTORS LICENSE NU; SEF:. . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE:)
INTERIOR ALTERATION WORK BY . . :
PHONE:
ADDRESS:
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 Of /C `�
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675