1993, 07-01 Permit App: 93005360 Sewer (4..6e, 0 _ kips uuttE �3y - i
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L SEWER CONNECTION PERMIT APPLICATION FORM 9- GJ-3(.0f
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
>7Z/7 ( IF KNOWN)
JOB ADDR SS:
l/2 U c J PARCEL NUMBER:
CITY:o ! /�j.e STATE:'/AV' ZIP CODE:
' ADDRESS: rads-.-P
OWNER NAME: -��
CITY: STATE:
PHONE: 92 '--4- 75'CS-
-.- )
OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES �
PROPERTY (CIRCLEONE)
*IF PROPERTY OWNER IGSEWER , THEY MUST FRST REQUIREMENTS BEFOREIPERMITNISCISSUED .THE TILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: I'-RIAS(2AN&O.ONS?P_ laION ADDRESS: ?.Q..P.O. Bak 1112137-
CITY: SPOKRNE, 110Pc S�A-T : clgal4 PHONE: q2a"0559
STATE CONTRACTORS LICENSE NUMBER . . : AQMS-CC*9..9N1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? N (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : Lech b
e-1/-4.-,..-7,4;
PHONE:_ 2 4'-- d` 2.--
ADDRESS:
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 = 3,S--
TOTAL PERMIT FEE DUE $
APPLICANT'
SIGNATURE�.`,
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675