1993, 05-07 Permit App: 93003278 Sewer 93 . 71
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED ISSUEUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT
D .
( IF KNOWN)
PARCEL NUMBER:
JOB ADDRESS: r '
STATE:rc
. ./i ZIP CODE:
CITY: Pl�)�l / --rr�
OWNER NAME: : ► ADDRESS: 0: 71(e) "` ' V�
9 (Q -9,c-a.t+
CITY -�--
STATE: �, __ PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY
MUST FIERST COONTACT ISTHEDHE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS
CONTRACTOR: TLC CoNsTP-UCTIoN ADDRESS: 6 . i38I(O )21'1 AVE
"Lp •. �RLID PHONE: g21. (O1100
CITY: SPOK�N� WA c -
STATE CONTRACTORS LICENSE NUMBER . . :_
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :________
PHONE:
ADDRESS:
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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35.00 =
TOTAL PERMIT FEE DUE $ ‘5t11101-
APPLICANT
‘5t11101-APPLICANT
SIGNATURE .4,119 0.
INGS
SPOKANE COUNTY DESFOKANETWARTMENF99260D( 509 )456-3675
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