1993, 10-06 Permit App: 93009394 Sewer �521Z , 101)
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) q 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 .
n
( IF KNOWN )
JOB ADDRESS: /;1/24 (f yPARCEL NUMBER:
STATE:k4 ` ZIP CODE: 9",; DV
OWNER NAME: / L( ADDRESS:
CITY: STATE: PHONE: /
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES d•
( CIRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: A 4 5 CO R6-I-(u(,kiorl ADDRESS: l 1 E311 t VaA le /!6v
CITY: SFol(a ne. STATE: V./A gG20HONE: 5oq • 92-6 . gr,i4
STATE CONTRACTORS LICENSE NUMBER . . : 14 CON 44 E- 12_3 Kt
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 .
00
SEWER CONNECTION # OF BUILDINGS // X 50 .00 = -Tr --
INTERIOR
TrTINTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
aTG'
TOTAL PERMIT FEE DUE $
APPLICANT /://
SIGNATURE 'Ad.,/7' 4(`-ke2
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675