1993, 05-14 Permit App: 93003513 Sewer (15D-1007,2_
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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: E . 13412 LOIC< PARCEL NUMBER:
CITY:
( 40 STATE: WA ZIP CODE: cral c
OWNER NAME: VILuAA6 ADDRESS: ZaJv&JI,
CITY:
STATE: PHONE: 9 Zg - (00/. •
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES LO
( YISCLE ONE)
*IF PROPERTY OWNER INSEWER , THEY MUST STALLING
BEFOREIRST PERMIOTNISCT THE ISSUEDUTILITIES
DEPARTMENT FOR CONTRUCTION
CONTRACTOR: CO tl-etf/kj&)F E CAVhT olO ADDRESS: E_ /(p(1aa liatlarvai
CITY: Vpci&do (Q_ d ATE� g9037 PHONE:n- � � p�
STATE CONTRACTORS LICENSE NUMBER . . : `�"u'c `w--'"-�
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : QDi4ek-( � P
ADDRESS: C (4( Pr-Lk( PHONE: q aa- 15y✓
CITY: C�ree.4QCreiS STATE: WA 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 = 50
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 85
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675