1993, 11-15 Permit App: 93011098 Sewer t� C
q33 - 1013
c13, i itcE
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 .
t� ( IF KNOWN )
JOB ADDRESS: : -r (1 &.;.r PARCEL
PARCEL NUMBER:
CITY,$"f C � STATE:Et A - ZIP CODE:
OWNER NAME: 1".1Plky r( UrP ADDRESS: -5. 11()a -, �Prk-P
, l
CITY 5 (' Ake STATE: td-4 PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CISCLE ONE)
RST
T THE
*IF PROPERTY OWNER INSGSEWER , THEY MUST REQUIREMEN75 aEFOREIPERMITNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: TLC- CoNSTEUC,TtON ADDRESS: E 138I(0 /Z AVE
ZIP
CITY: oKPAZ LL)A S-fi fiE' C1C\ PHONE: Gad
STATE CONTRACTORS LICENSE NUMBER . . : CCO L&7T1 L
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 411,11 (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 = �° 0
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ 5-0. 00
APPLICANT
SIGNATURE ,./<(),..
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675