1993, 07-20 Permit App: 93006056 Sewer C35 — 53
- �� 5_
c.
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: a7OS S. lLi er PARCEL NUMBER:
CITY: Sec_k« STATE:( ZIP CODE:
OWNER NAME: CA-)ck(1- �+'ectADDRESS: --914/"1 --
CITY:
914/"1CITY: STATE: PHONE: C/2-4-(-23s
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( YIRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: lb- 5 ADDRESS: (ISO F° Uc
CITY: q02,16_, STATE: PHONE: q ')60
STATE CONTRACTORS LICENSE NUMBER . . : rc.>,v 1231: F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? c YES NO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : 140
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 = 61 -4,057
TOTAL PERMIT FEE DUE $
APPLICANT j
SIGNATURE C
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675