1993, 11-24 Permit App: 93011444 Sewer ctp39- - ) 1-4 (4 9-
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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 .
( IF KNOWN )
JOB ADDRESS: (— / 5Z)/ " q PARCEL NUMBER:
CITY: 5, ,,,-4«( STATE: WA- ZIP CODE: 62772OI
OWNER
NAME: 2 2 / / 1 l� vici
ADDRESS' f / o 5-a-/ q
CITY: Sle-. STATE: ((PHONE
PROPERTY OWNER PERFORMING SEWER CONNECTION3M ALLATION? YES
(CIRCLE 0`0
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: (:)70/,,S /J
cc.4 �� °�`' ADDRESS= �� / Z� AZA =-°`>
CITY: L/e✓ .4 STATE: 14- PHONE: q Z6 -Y7J 73
STATE CONTRACTORS LICENSE NUMBER. . : Cit cL J 077 PAS
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 61;) (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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
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REGISTERED AS PROVIDED BY LAW AS A:
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REGISTRATION NUMBER
EXPIRATION pA }
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F 1642 3 8Ftpiq wAY10
RADA tiA SIGNATURE
/ 99037
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ISSUED BY DEPARTMENT OF LABOR AND INDUSTRIES
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