1993, 06-08 Permit App: 93004426 Sewer 01 3 - 14(CZ
3510
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: 1311(9 C I II^ PARCEL NUMBER:
CITY
Spolcu-e STATE: Lu A. ZIP CODE:
OWNER NAME: 0 c4-d� N,„
ADDRESS: _
CITY: STATE: PHONE: 92`{
CONNECTION INSTALLATION? YES NO
PERFORMING SEWER
PROPERTY OWNER ( CIRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: (-1k-3 ADDRESS: I (81 F
CITY: Se
plc (,� STATE: (--c PHONE: Y< - -/(Qq
STATE CONTRACTORS LICENSE NUMBER . . : _S_C�r� , KF
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 1 X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FE EWE_
1993
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675