1993, 12-10 Permit App: 93011847 Sewer ., q.� -0g4-7
165
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: 4/90/ E' / PARCEL NUMBER:
CITY:
25,71004-;16./4-1 STATE: (J/21 , ZIP CODE:
OWNER NAME: ADDRESS:
CITY: STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES( CISCLE .NO
*IF PROPERTY OWNER INSGSEWER , THEY MUST REQUIREMEN7S BEFOREIRST PERMIOTNISCT THE ISSUED.TILITIES
DEPARTMENT FOR CONSTRUCTION
TLC- coNST2UC.T(ON ADDRESS: E. L38I(0 i2 " AVE
CONTRACTOR: ZIP
CITY: S47oKAAE LL)A STATE= cAZ‘(o PHONE:
STATE CONTRACTORS LICENSE NUMBER . . : -CCO r1F*A-O`Th L.P
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (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 ( X 50 .00 = 50,OP)
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ e)0
APPLICANT
SIGNATURE __alio .
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675