1993, 07-022 Permit App: 93006138 Sewer ►' G� ,i 1. ,' j � r Jima, r`-( r93 - 43 .2(P
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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: 1321 C- IV-l..- PARCEL NUMBER:
CITY : COCcf=' STATE: G4 ZIP CODE:
OWNER NAME: 16^^ i ,�t�r ADDRESS: - V-s...rQ
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PHONE:
CITY: STATE: ( Th
PERFORMING SEWER CONNECTION
PROPERTY OWNER INSTALLATION? YES ' NO
(CIRCLE ONE)
*IF PROPERTY OWNER
CONSTRUCTIONINSTALLING
REQUIREMENTS BEFOREFIRST
PERMICONTACT
UTILITIES
DEPARTMENT FOR ISSUEQ
CONTRACTOR:
ADDRESS: 1°67 5-. ( )Ld r:
CITY: ' k STATE: t,rm PHONE: 3�Co- X4-7 (
STATE CONTRACTORS LICENSE NUMBER . . : N-S- w u tx (2-)31(-1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES ( 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 X 50 .00 =
Jv
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675