1993, 12-27 Permit App: 93012164 Sewer 9-3 - 16+
i5 - 1122.
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 . e
( IF KNOWN)
JOB ADDRESS: g / 3 �01 I� PARCEL NUMBER:
CITY: Sn STATE: W 1 ZIP CODE: TC)--0467.TC)--0467.
OWNER NAME: �//— 1c/r -r ADDRESS: /3 iU 2 /d�
�/
CITY: 506`-'` STATE: 4-14' PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
(CIRCLE
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
/ ADDRESS: ��/0
CONTRACTOR: (/ fix /�`v
CITY: �� " STATE: 5.CW PHONE: .-W-2- �-Z
STATE CONTRACTORS LICENSE NUMBER. . :
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 = .5 U
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ SZ) --
/
APPLICANT / / Off,
SIGNATURE .7
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675