1993, 10-05 Permit App: 93009310 Sewer 14-5&g( `01-01 (13 -ci.310
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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: , ' 7Y V �> PARCEL NUMBER:
CITY : � STATE: � ? ZIP CODE:
OWNER NAME: ADDRESS: 7-4P('1‘2/
CITY • =�.Z STATE: ��,/ PHONE: 8- %K2-)
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PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: CuRNAI NE EXCPSVATioN ADDRESS: E. - 101-LO 11-AU_E'WA`1 I° 16
CITY : VE J DRtE VP - STATE: q907 PHONE: gay_ 54F)5
ST^TE CONTRACTORS LICENSE NUMBER . . : COUZCC*".1.81Q1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YE NO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : C. 6)
ADDRESS: . /�T A) ax J PHONE: - / -
CITY: c AP_C�CSTATE: /7 '' ZIP CODE: 452
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER . c0 '64I
SEWER CONNECTION # OF BUILDINGS X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = Z
TOTAL PERMIT FEE DUE $
APPLICANT 4Q-61-/t(L47-
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
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12,30,93
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