1993, 07-01 Permit App: 93005354 Plumbing Reversal rAs
(f)- Mf(14'4P
C) 3 3DL1
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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: r PARCEL NUMBER=
CITY : t.„0,../ STATE'r///* ZIP CODE:
OWNER NAME:far, ADDRESS: i
CITY: STATE: PHONE=
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES ( 7
YISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CsNSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .%\
CONTRACT : A01moi_- �-
ADDRESS: /?G) a2 mac/ -
i
STATE / PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? 4111Er NO ( 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 /I X 50.00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS f X 35.00 = _LEA
TOTAL PERMIT FEE DUE $
APPLICAN „
SIGNATOR � _ ,A11111111111011'
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675