1993, 11-05 Permit App: 93010753 Sewer 145t04-, Orq, - `B -lD7E3
u..q, -FL 9s7
LIZ 81 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:- / /7 PARCEL NUMBER:
CITY: �., Xe4-L_P__ STATE: A)(1- ZIP CODE:
OWNER NAME: 7 .-(A--e_ /,'(_/4'7a ADDRESS:
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: - 4S CO R6-1-ru ADDRESS: I 8 1 l \I0.1 ley o/01
CITY: -60 L ' € STATE: V,IAgat PHONE: SExi • G2.b • q(o�-�
STATE CONTRACTORS LICENSE NUMBER . . : 4S ( 44- 123 Kc
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 .
Y
SEWER CONNECTION : # OF BUILDINGS / X 50 .00 = 5 c�
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ 3(2
APPLICANT
SIGNATURE (l ,1.0/44---
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675