1993, 09-02 Permit App: 93007537 Plumbing Alteration 7)a 69L--/
SEWER CONNECTION PERMIT APPLICATION FORM
' r
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRELY'
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
/ ( IF KNOWN )
�,2 e9 S /� i PARCEL NUMBER:
JOB ADDRE� �
CITY: v/
STATE a'- ZIP CODE: .- /4
�� // ADDRESS: �1 0
OWNER NAME: /P,/�C�
CITY: STATE: PHONE: 9, C".- 2
YES NO
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CISCLE ONE)
*IF PROPERTY OWNER INSTGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMITNISCISSUED .THE TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: ARVISTrzoNe,eoNS-ralCTioN ADDRESS: -Pf 0• Bak 14 28 7-
CITY: SPOKPNS A E: g9PHONE: Cag-0559
STATE CONTRACTORS LICENSE NUMBER . . : AeMST -e
5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? L. " - frre (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 /I X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = 3s
TOTAL PERMIT FEE DUE $ o's
APPLICANT �
SIGNATURt-
SPOKANECOUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675
AUG-31—'93 TUE 15:55 ID:TUMWATER LOCA*?tION.^- TEL NO:206 239 5461 #716 P01•
DepartmentofLabor induatsia REGISTRATION VERIFICATION
Contractor Registration Section " ,
PO Box 44450 iv!'"
(2o6)956.52'26Olympia WA 98504.4450 SCAN 2695226
FAX(206)956.5228
--• - Olympia Headquarters• 4\kST
%—‘cki
Contractor: Your Certificate of Registration will be sent from the Olympia office and
should be received within 2 to 3 weeks• Please keep this record until you receive your
Certificate of Registration. Than , you
F625-036.000 rogbotaian verification 4-93 "�