1993, 12-06 Permit App: 93011696 SewerSEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
/I, ( IF KNOWN)
JOB ADDRESS: -__V/8) S /,
, Vow 22) PARCEL NUMBER:
CITY:�1,of,21_,- STATE: /L__ ZIP CODE: 9.;?/%g
OWNER NAME: i://, 1.Y.1179-nJ ADDRESS:
STATE: PHONE: c,7,' -,1/s --
CITY:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: 144S- CO r16-hru (si" r ADDRESS: 11,611 e .
CITY: •6pOY,G11 c. STATE: v./Aact2 PHONE : SE G . G26 • cl��
STATE CONTRACTORS LICENSE NUMBER..: 145 LD N 4k* 123 KK
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES () (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 = _'1/ -
INTERIOR
INTERIOR PLUMBING ALTERATIONS: f# OF BUILDINGS X 35.00
TOTAL PERMIT FEE DUE $ s�
APPLICANT
SIGNATURE 7'..I//4' _%�.�/�9�f/1
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
0
RECEIPT Date II -AO 19 13 0964
Received Frpm -ink.rJ 0 • Vlicir,S -e r
Address N —7308 C cps. )0 -ray tkoNkEs
VE2(,,'O. 1106 Dollars $ 525 ca
For M3 Et cf.) elz_A. I FA- CA 1 t 4L:e 5
ACCOUNT
HOW PAID
AMT. OF
ACCOUNT
CASH
AMT. PAID
CHECK
BALANCE
DUE
MONEY
ORDER
By .4:.', AVva...S L
k
'
I