1993, 08-20 Permit App: 93007294 Sewer /75
Ldk0A •
d
SEWER CONNECTION PERMIT APPLICATION FORM '1 ._�
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED . C, 3 6(-
( IF KNOWN )
JOB ADDRESS: m /0 C i 1} PARCEL NUMBER:
CITY : S(3,k u— STATE: Lt ZIP CODE:
OWNER NAME: �c,.0-1 S) i Z� ADDRESS: Sc_ -
CITY: STATE: PHONE: ciLco-C.eYi7
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEDS.
CONTRACTOR: 1--1 -5 ADDRESS: 1 1 8 i l v4+t-r,-7
CITY: Ser,k STATE: t_iq PHONE: q Co x50,1
STATE CONTRACTORS LICENSE NUMBER . . : I-1 S C a P u b
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YESJ NO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : 1-1 -5
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
n
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 $
APPLICANT mac=
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
a
_ .\�. -.1� A.--
Cdl \\1N�1
\\ .�e�\\1tv�_Ae
---_ \\eh\.\�i.\h\\l�lie\h`�\l1" e.1\\ ta211.1Z.
( DEPARTMENT OF LABOR AND INDUSTRIES
I` REON IS REGISTERED AS PROVIDED BY LAW AS A i
•
THIS CERTIFIES THAT THE PERSON NAMED HE I
x
'al ST Ct N,x - 6E$ERt i,. Afi:
1 ,,,:,,4,0!''"--
tet' '� REGSTM * A ' STATE OF WASHINGTON
y F
"r t�. j r y�' "'.., w ki'Y ' i ,Xyy1:.,....ittiplts'i,S70,..zt41.4:::11:',,,,,,..,,..71::!:° ►(fWA 99011
-
F625-052-000(3-921
. 70.:,, ,
\\\�.�A "-------- --------NNX"'" :"..V.Vir.\.:7•:,.. yy
i,
i4i'liii'fil:'4)illirt'v115":
;iiiiiiiii"•h�Yy
�. '',-4.;';1,tri`` t ``�� "4
t. 4
{ f
i:'`: ,, t 'it3 : zi �3'ii .it ti z " `'' : i'' a -i I:, ;tif`'� #i
,t
t