1993, 06-09 Permit App: 93004750 SewerZ -q q 35 3q �5
93 -H'75�D
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.
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JOB ADDRESS: / U 70 8 � PARCEL NUMBERe
/ U4 ZIP CODE:
CITY �JK�A^<- STATE
OWNER NAME /A C� i9/ba>-C ADDRESS: /--
i 4 PHONE: ��L'igSU
CITY ��� ^v STATE
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR:
CITY:
ADDRESS:
STATE PHONE:
STATE CONTRACTORS LICENSE NUMBER..
UTILITIES INSTALLERS PERMIT NUMBER!
INTERIOR PLUMBING ALTERATIONS?
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY
YES NO (CIRCLE ONE)
tM. a am
STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION .............: # OF BUILDINGS _ I X 50.00 = SO.o
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
TOTAL PERMIT FEE DUE R
APPLICANT
SIGNATURE�_�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675