1993, 12-10 Permit App: 93011854 Sewer CI3 '( 18.511
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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 .
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( IF KNOWN )
JOB ADDRESS: CL 2 A ' PARCEL NUMBER:
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CITY:, -4A STATE: /,,J v ZIP CODE: WeV
OWNER NAME: 44 4 /144ADDRESS:
CITY: STATE: PHONE: 2,2d' —i2,:,9S
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES <1
( CIRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: S CO f1.5÷f A rAieOri ADDRESS: 1 18 1 r1 e. \IOU lej oi(V
CITY: -6FOkfUl2,. STATE: VJA PHONE: SExi • c12.6. • $cu
c1ci 20
STATE CONTRACTORS LICENSE NUMBER . . : 145 CDN a4 * 123 K1=
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 it OF BUILDINGS / X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ l
APPLICANT /
SIGNATURE (
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675