1993, 10-25 Permit App: 93010258 Sewer OL4 are-hos-ats qq - 10 2,5g
'135 - gig
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUSTNOTIEU
E FILLE
ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
J gD/- ` ( IF KNOWN )
JOB ADDRESS: 5v
1� 8 CJ( � 7 ( /7 PARCEL NUMBER:
CITY'SpQ�-A N ,
STATE: = ZIP CODE:
OWNER NAME:S iN ^^ W r v i f ADDRESS: ( 0 S CO '
'5r0k(P1 STATE:LI)� •
PHONE: O �79 -`t Ao�
CITY1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES( CISCLE 0 NO
*IF PROPERTY OWNER INSTALLING �QUIREMENTS BEFOREFIRST
PERMIOTNISCISSUED.THE UTILITIES
DEPARTMENT FOR CONSTRUCTION R
CONTRACTOR=
TLC ('A NST eUCT(o N ADDRESS: E. 33810 12-01 AVE
CITY: SPoKAIJE LOP, sThitsTE= Ggal(0 PHONE: Ga'1 -L0 I
STATE CONTRACTORS LICENSE NUMBER . . : LCCO rk4 a-.O 7M Lp
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE:
ADDRESS:
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 = 5fl,d b
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 =
TOTAL PERMIT FEE DUE
APPLICANT
SIGNATURE . mgy ' 'dik r
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675