HomeMy WebLinkAbout1993, 10-11 Permit App: 93009593 Sewer 213- qo •
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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: (U iq 17 E 2�� PARCEL NUMBER:
CITY : c 1,_1 STATE: `)P6 ) ZIP CODE : q41)-01
OWNER NAME: ��L C 1/. DAral A-57/A.C,5 ADDRESS: 5 - V5 V LLD Car)
CITY : U,ygiut STATE�l.J. 4\ PHONE: ami -5185-
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFOREPERMIT IS ISSUED.
CONTRACTOR:' DYYI $`-0L ADDRESS: Ad 1 1 i Z 1'hi v'1, 2 /2.0
CITY : 0 1C�LvLSTATE: PHONE: q)4-- 7710
STATE CONTRACTORS LICENSE NUMBER . . : -1-bfYlcl L4 t - K)CV\
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 6\D ( 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 .
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SEWER CONNECTION # OF BUILDINGS ( X 50 .00 = `SCS `--
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ `—
APP N I T Z I�C�
SIGNATURE
SPOKANE COUNTPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
REGISTERED AS PROVIDED BY LAW AS A. • _ __
'REGISTRATION
NUMBERNbM
r '� E EXFIRgppy�BATE
11
• FP C . O.414? 04
P
rom sr ONE' ex A
U 33 x 14, 54 V✓ Tt tiG
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992140154
IssuED sy DEPART'T OF LABOR AND INDUSTRIES
SIGNATUR:�