1993, 07-08 Permit App: 93005592 Sewer 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 )
OC; 5
JOB4-72-010t � ��
C?
ADDRESS• . /� PARCEL NUMBER: 1 -
CITY:- 00/-09/0L) STATE: G(,),9 ZIP CODE: .�-� 1 �,
OWNER NAME: A4O2A /j/ fChvL,, ADDRESS: )//// 79 Cr 014'4)/
CITY: 077s CWEJ///,46es STATE: w/9 PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( YIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR:S/m So,J SA.)/r-T/o4) ADDRESS: 7.37/.2, 6 &/ &0/4)
CITY: SPui-09,-) STATE: /J,d9 PHONE= (,.? 6 - -VP /
STATE CONTRACTORS LICENSE NUMBER . . : /�t'ss. /9a C_
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 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675