1993, 09-09 Permit App: 93008136 SewerSEWER 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 PARCEL NUMBER'
CITY: STATE�6Q�_ ZIP CODE:
ADDRESS n �' O
OWNER NAME= �y /
CITY
STATE PHONE: /� 7-
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
RST
T THE
*IF
OWNER SEWER, THEY MUST BEFORE PERMIT ISC UTILITIES
ISSUED
CONTRACTOR ARIYIST2AN6 C�DN-UCI•ION ADDRESS: ?0• Bo*, lyz67-
CITY: SPOKANE. W P. T- qq a�4 PHONE= 9 '0559
STATE CONTRACTORS LICENSE NUMBER..: AeMSTG+hl9e�N1.
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?(yE� NO lr�2 (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: (((
ADDRESS
CITY:
PHONE:
STATE= ZIP CODE=
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
=
SEWER CONNECTION ............. c #
OF BUILDINGS
X 50.00
INTERIOR PLUMBING ALTERATIONS: #
OF BUILDINGS
X 35.00
= �—
$ g l�
TOTAL PERMIT FEE DUE
APPLICANT
-
SIGNATURE
SPOKANE COUNTY
DEPARTMENT OF
BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA
99260 (509)456-3675