1993, 10-07 Permit App: 93009505 Sewer4532 4 Igo' q3-95.5 x ,63
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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.
JOB ADDRESS: „ y 7 3
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�� ��� STATE: I/q' ZIP CODE: _9a��iio
CITY:
(IF KNOWN)
PARCEL NUMBER:
OWNER NAME: �)LJJ c-,41 ADDRESS:
CITY: STATE: PHONE: 9,979-221/77
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: t- 5 CO 11.-+. ADDRESS: 11,611
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CITY: S k e- STATE: \NIA PHONE: D - q2 , • PC42 "
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STATE CONTRACTORS LICENSE NUMBER..: 145 CONI -* 123 -KC
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 - ## OF BUILDINGS / X 50.00 =
ce
INTERIOR PLUMBING ALTERATIONS: i# OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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WA7aNVONNA: V1/4WANN.
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DEPARTMENT OF LABOR AND INDUSTRIES
This CERTIFIES THAT THE PERSON NAMED HEREON IS REGISTERED AS PROVIDED BY LAW AS A
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