1993, 07-20 Permit App: 93006054 Sewer 93 - a5Lt
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: D (-O`CP S' `(-4"-- PARCEL NUMBER
CITY : �eok STATE= WA ZIP CODE:
OWNER NAME:
Lj l l, S ADDRESS:
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(YIRCLE ONE)
*IF PROPERTY OWNER INSTAGSEWER , THEY MUST REQUIREMENTS BEFOREIRST PERMIONISCT THE ISSUEQ TILITIES
DEPARTMENT FOR CONSTRUCTION
� utic
CONTRACTOR: W+S ADDRESS: 1181-7
CITY: Sed c.w-. STATE: Lon PHONE: C12(2- y :4
STATE CONTRACTORS LICENSE NUMBER . . : I-(- S Cc'n' 4 ' 13 K F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES C. N0 ( 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.
4 ;-L)
SEWER CONNECTION
# OF BUILDINGS X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 =
TOTAL PERMIT FEE DUE $ C6
APPLICANT
SIGNATURE I (c)--/- —
SPOKANE
COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675