1993, 04-16 Permit App: 93002614 Sewer \i)C4C Z(191q
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 ) L15.W.I ! (32,
JOB ADDRESS: I j 3/3 c I (-11, PARCEL NUMBER:
CITY: Specks--a STATE: WA ZIP CODE:
OWNER NAME: ,kctc k., ADDRESS: + -
CITY: STATE: PHONE: q _ c'64`?
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 ISSUED .SSUED .
CONTRACTOR: f-1 + ADDRESS: 11811 V� C(, (w1
CITY: �� cc, STATE: �-t ' PHONE:
STATE CONTRACTORS LICENSE NUMBER . . : l'"S Ccs t) - 12 3 4- F
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES CNO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : `14 14-Pr
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 1 X 50.00 = S v
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