1993, 08-03 Permit App: 93006582 Sewer u km-Fc rts-b
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:
/� aPARCEL NUMBER:
�
CITY:
STATE: "2 // ' ZIP CODE: q1 G a14.,
OWNER NAME: 4C..t4,4miCADDRESS:
CITY:
STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 4P
(YISCLE ONE)
*IF PROPERTY OWNER INSTAGSEWER , THEY MUST FRST REQUIREMENTS BEFOREIPERMITNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: AR.IYIST ON&CON5Teal'iON ADDRESS: ?.O. Bak 142137,
03
CITY: SPOKN 1ti}Pr S A E-: g9aiy PHONE: Cab-0559
STATE CONTRACTORS LICENSE NUMBER . . : AVMSTCy03-9a N1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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 = y ,
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = _._n
TOTAL PERMIT FEE DUE $ C �
APPLICANT
,/
SIGNATURE �-� r�'� -dt.`
SPOKANE COUNTY
AVENUEDEPARTMENT
SPOKANE,WAF99260BUILDINGS
( 509)456-3675
WEST 1026 BROADWAYY