1993, 04-22 Permit App: 93002793 Sewer o � � - z 013 q3 2��3
C5-PP SEWER CONNECTION PERMIT APPLICATION FORM
*THIS
C5-PP
FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN )
JOB ADDRESS: j3 z- E L`-1 <<c- PARCEL NUMBER:
CITY: p,;ti, <r.� STATE: i�N; ZIP CODE:
OWNER NAME: rid. Su -, ADDRESS:
CITY: STATE: PHONE: 3:1-c'-c)216v
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (_14.0'
( CIRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: 1-(-*S ADDRESS: di C 1
CITY : V,k�., STATE: (--(A PHONE: 7G Xc7 �`1
STATE CONTRACTORS LICENSE NUMBER . . : « ` '_L,^) kx I L IC F.
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES C—jr: ( 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 1 X 50 .00 = SJ
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ SU
APPLICANT > '
SIGNATURE �
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675