1993, 05-17 Permit App: 93003604 Sewer ASg3-`-\ ‘u-7 4 cooq
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: Lam . /33 / 9 T PARCEL NUMBER:
CITY: 5-/964:=
STATE: V144 ZIP CODE: '75 Z0 6,
/3 z' ADDRESS:
(5;
OWNER NAME: R iS
CITY: STATE: PHONE: ~
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES ' NO
(CIRCLE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: A'(,WA''jS AC-T1VE ADDRESS: o, Box t 4`5(c a
2A?
CITY: SroKPNE ‘414 S- ATE= %g iu PHONE: q@D -8,500
STATE CONTRACTORS LICENSE NUMBER . . : ALWAIAat4.0(0P5
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 6_/1) ( 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 $ JO —
/'
APPLICANT
SIGNATURE
NE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675