1993, 07-20 Permit App: 93006059 Sewer 1.4 c33 53
q3 q
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: 1 ) 10`; C , C3 41^• PARCEL NUMBER:
CITY: S(DIko-sz STATE: (Air ZIP CODE:
OWNER NAME: I)cr, ]T,�c 4�'�r
ADDRESS: -- 54-0-t-51,
CITY: STATE: PHONE: i 2y - 2403-1
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
N
( CIRCLE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: pf3 ADDRESS: J ?
CITY= 1c..., STATE: wn PHONE: iago- Yi(.oq
STATE CONTRACTORS LICENSE NUMBER . . : 1-I-S- Cc, J 'r 123K F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES :' ( 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 $ <L)
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675