1993, 12-10 Permit App: 93011844 Plumbing Reversal /-Fc . 12_ 13 ' 1L 'fr
I ' ( l
SEWER CONNECTION PERMIT APPLICATION FORM ' / / Lf"
*THIS APPLICATION FORM MUST
NOT FILLED
BE IEDUOUT AACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
/ / ( IF KNOWN )
JOB ADDRESS: /0 6 G � n � PARCEL NUMBER:
CITY- v (t/9N/
_ . STATE: 12)4 ZIP CODE:
�
G-h OR I � �E�°SON ADD ESS: ( V (t�C co T. 61-4\
<\
OWNER NAME: 9 a 1pti
CITY C�-Kfl A STATE: PHONE: O
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CIRCLE •
*IF PROPERTY OWNER INSTALLINGREQUIREMENTSBEFORESEWER , THEY MUST IPERMITNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
1 'LC�. 'oNST2.UC.TION ADDRESS: E . 1:581(0 i2 AVE
CONTRACTOR: Zip
CITY: SI7oKL6A S fiE: ggakc0 PHONE: Ga-1
STATE CONTRACTORS LICENSE NUMBER . . : LCC O APA 1'O 7T1 LQ
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 1 X 35 .00 =35.00
= 5o • O sn
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS C�
TOTAL PERMIT FEE DUE $ S . 1-) 0
APPLICANT
C
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675