1993, 12-21 Permit App: 93012077 Sewer . .
93 l 77
qj5 -1112
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE
FILLED
DDE UOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT
jh,,.!? . ( IF KNOWN)
JOB ADDRESS: Ye _ J L. PARCEL NUMBER:
CITY: KfolL
STATE: ZIP CODE:
OWNER NAME: " cam ADDRESS: A'
C-- i STATE: ( PHONE: 1 d--`f � -3
CITY: ��
PROPERTY
OWNER PERFORMING SEWER CONNECTION INSTALLATION? CES
RCLE )
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACTS THE0.UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT
CONTRACTOR: CSC C., ADDRESS:
CITY:
STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER. . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY. . : •
PHONE:
ADDRESS:
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 = ` C) �
=
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 ��, �
TOTAL PERMIT FEE DUE $
APPLICANT 1{6SIGNATURE 404I/
SP' A E OUNTY DEPARTMENT OF BUILDINGS
WEST 10 .6 : OA II 'Y AVENUE SPOKANE ,WA 99260 (509 )456-3675