1993, 06-02 Permit App: 93004438 Sewer Li 438
359 (A•
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: l f cc)4 S+L, PARCEL NUMBER:
CITY: SpA r_,.o STATE: wn ZIP CODE:
OWNER NAME: L i L4-))1 l i'-AADDRESS: —
CITY: STATE: PHONE: q2-2--1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE-1
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: � ES ADDRESS: Het ..?
CITY: 44lLc STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . : 1 Z3 1C
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES N) (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 1 X 50 .00 = Sc)
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ 5 ,
RECEIVED
APPLICANT JUN 21993
SIGNATURE /
SPOKANE COUNTY DEPARTMENT OF BUILDINGS CODE ENFOhL,tMtNT
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675