1993, 09-23 Permit App: 93008775 Sewer .
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SEW
CONNECTION PERMIT APPLICATION FORM
OUT ACCURATELY*THIS APPLICATION FORM MUST BE FILLED AND IN ITS ENTIRETY 0715.'1
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AND SIGNED OR PERMIT WILL NOT BE ISSUED . WA-4.0 eg
G ( IF KNOWN) `�) GJ U, 070
JOB ADDRESS: 3-305- it.
E, PARCEL NUMBER:
�1 1
CITY
)*nI STATE: _L ZIP CODE:
OWNER NAME: : t kits- I ADDRESS:
33d - 411
CITY'
STATE:_ PHONE= Cia(0
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (YES NO
0 O
*IF PROPERTY OWNER INSTALLING SEWER, THEY
MUST FIERST COONTACTSTHEDHE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
CONTRACTOR: TLC CONS'T9.uCTt0N ADDRESS: 6 ' I38l(o )2. PAVE
zS1 Al gciR 16) PHONE: c121- 6,11420
CITY: SPOKRNE WA
STATE CONTRACTORS LICENSE NUMBER . . : 7L,CCOti 1Oi Ml0
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 461110 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 . 5c) no
1
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = 3-C-,0 03+
TOTAL PERMIT FEE DUE $ 15.00
APPLICANT
SIGNATUR - ' 111/;'` �a 6 4�`�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675