1993, 08-20 Permit App: 93007253 Plumbing Reversal•
SEWER CONNECTION PERMIT APPLICATION FORM
935 -633 -
*THIS APPLICATION FORM MUSTNBE FILLBE ED
DDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
JOB ADDRESS:
CITY:
?cq , ;7%
STATE:`k ZIP CODE:
(IF KNOWN)
PARCEL NUMBER:
OWNER NAME: O c !V ' \C c -CR ADDRESS : l , 7-14A
CITY: S C0 CAN)E, CAN)STATE= _
PHONE= GTPD,~SO Co
PERFORMING SEWER CONNECTION INSTALLATION? YES (1710-.)
PROPERTY OWNER (CIRCLE ONE)
*IF PROPERTY OWNER INSTGREQUIREMENTS BEFOREFIRST
PERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: TLC CoNS1eacTioN ADDRESS: E' 38N )Z AVE
?J- ggal(D PHONE: q2,1--(olt0O
CITY: SPoKP�N� WA ��'
STATE CONTRACTORS LICENSE NUMBER _ TI�CCOi 101 M(o
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? CYES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: -r----S tethq
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 =5-0100
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = 3S'0
TOTAL PERMIT FEE DUE $Z510-0
APPLICANT LAS10-
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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