1993, 07-09 Permit App: 93005617 Sewer 43-66011
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. KNOWN )
JOB ADDRESS:/3 gY E- �O-F/ PARCEL NUMBER:
CITY- 5;00,-;744F STATE:/A)/9. _ ZIP CODE:
OWNER NAME:G/c1A+ Oaf* ADDRESS: / 32/ 7 ,r. /O/-
CITY:Sl/J E
7j4A/. j / STATE:Z114 PHONE: 92, -/ 9�
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N0
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: TLC CONSTP-ucTloN ADDRESS: E i 1351(0 �Z PVE
CITY: SPoKRNS WA sy-rrrE, 990214) PHONE: 92-1- CelloD
STATE CONTRACTORS LICENSE NUMBER. . : TL.000AklLOSM4
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 0 (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 -= S-0, DI2
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = ---
TOTAL
TOTAL PERMIT FEE DUE $ ,S-n,OO
APPLICANT
SIGNATUR v
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675