1993, 08-04 Permit App: 93006612 Sewer rr-ri s-75
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: S- 2- — G-e ver PARCEL NUMBER:
CITY:
Sp�t � STATE: cw4 ZIP CODE: 992-06
nn s- 7-7-f 5/46-F�
OWNER NAME: Pa0 �D$6 Y ADDRESS:
CITY: Spoia) STATE: 6/4 PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 4g)
(YISCLE • • )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .7
CONTRACTOR: �� ����`''� ADDRESS: PP eel(
06
CITY: 0PPo,2-raN,r, STATE: WA PHONE: 1'Z1--6671
STATE CONTRACTORS LICENSE NUMBER . . : kEO6 t --7.- j°s'kc9
UTILITIES INSTALLERS PERMIT NUMBER: 5- 21 - clq
INTERIOR PLUMBING ALTERATIONS? YES 652 (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
r�J
' SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675