1993, 07-26 Permit App: 93006279 Sewer oups ..2.1 3- 9\az)0
°13.
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: (/a(l — lit E- - l+� PARCEL NUMBER:
CITY : '(Dule--,,,,e STATE: F-r ZIP CODE:
OWNER NAME: —7L"--° 141 ADDRESS: 12236S—
CITY:
Z3dSCITY: CCe6I(- STATE: PHONE: q2-2' ZC
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CIRCL ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUELI.
CONTRACTOR: ADDRESS: Or? (k((.rcrl
CITY : rUj(—off STATE: WA PHONE: q cl (_9
STATE CONTRACTORS LICENSE NUMBER . . : (/—S— CON I z3 K C
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 = SU
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ SL)
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675