1993, 10-05 Permit App: 93009305 Plumbing Reversal` 43-43Qs
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.
JOB ADDRESS: / 3. /�fE
CITY: _S' " STATE:
(IF KNOWN)
PARCEL NUMBER:
ZIP 'CODE:
OWNER NAME: � �-��� ADDRESS: /—�' —,- /9 ,--- le�r ef�we-
CITY: STATE: PHONE: 9�6-302.
PROPERTY OWNER PERFORMING WER CONN TION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER IN ING SEW R.
THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: CPIARCHmg- EXCAVATION ADDRESS: E.Iby.OR VAU.EYWA'I P{V6
CITY: VE2ADALE W P.TSTATE< ClgO PHONE: gall- X455
STATE CONTRACTORS LICENSE NUMBER.. COU2CCa"�S1R.`I
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS?,,ESJJ NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..: Yl��JJ 1 -PWS. 41 / Y7_ t/�-�l,Cf��- d
ADDRESS: �tY /�iS� �C�-l:�c� - V 'PHONE:
CITY: STATE: J 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
TOTAL PERMIT FEE
DUE
APPLICANT 9/oi
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SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675
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