1993, 08-03 Permit App: 93006586 Plumbing Reversal� . �
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SEWER CONNECTION PERMIT
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APPLICATION FORM "-F.ptsP1,. Z -Z1-93
AND IN NTIRE04)
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: /(-- e 7
CITY: STATE:
OWNER NAME: 4ift---1/Pry. eg��so
n
n
CITY: 0 KV PLU STATE:
WA -
ADDRESS:
(IF NOWN)
PARCELI<NUMBER: `30`A / . /d,Z0
ZIP CODE: qgo11
Y V / PHONE: Caw) 9-S v -
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION?
NO
CLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION WORK BY..: /16//`4h/"f
ADDRESS: /7) 1//' ' e / (la'
�
CITY: 0%i0 6 f� n
1JJ
NO (CIRCLE ONE)
STATE: U/4
g egvie..50
1
PHONE: (seq) q; -3g5 —
ZIP CODE: V7140
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION
INTERIOR PLUMBING ALTERATIONS:
00
# OF BUILDINGS X 50.00 = 50
# OF BUILDINGS 1 X 35.00 = 35eS
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOK-NE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675