HomeMy WebLinkAbout1993, 05-27 Permit App: 93004018 Sewer 5-aL\ ,20--.›____, 0 dot
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331 SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUSTNBE FILBEIEDDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WI
C i 2'� PARCEL( IF '<NUMBER: 5-.22Yl 3/03,
NOWN )
JOB ADDRESS: Limo q
CITY : 5pa ,r.�KaSTATE: laQ ZIP CODE: .-2/b
�2Th
OWNER NAME: 1�oxn f 1(YU�b�nrn t'v� ADDRESS: 1310
CITY: Spc,ka►l lo
STATE: V-' Ck PHONE: 924,1_-2wg
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? alt,
LE ONE)O
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION R n R M . r afg- ' t IeI &4 TUVLtZ7,0�;,{,
CONTRACTOR: ADDRESS: /2*-
CITY: STATE: ___ PHONE: / C.v
STATE CONTRACTORS LICENSE NUMBER . . 4*
UTILITIES INSTALLERS PERMIT NUMBER: 0-
INTERIOR PLUMBING ALTERATIONS? YES t\ :/ .' (CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . : /a4-
ADDRESS:
'4ADDRESS: ;0' /14,-- PHONE:
PHONE: /4,
ZIP CODE.�
CITY =
/�ice /�f STATE. �Lr-
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER .
�AQ�
SEWER CONNECTION : / # OF BUILDINGS / X 50 .00 = _=0_____
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 =
TOTAL PERMIT FEE DUE $ c201j
APPLICANT DQ��
SIGNATURE 442GQ/1.�G(
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675