1993, 10-06 Permit App: 93009451 Sewer g3 -9L/s1
13,5 - g33
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 .
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( IF KNOWN )
JOB ADDRESS: / 3 I Z-I ZF- ( PARCEL NUMBER:
CITY: S o/ct; we STATE: 01 ZIP CODE: ? c17/ 6
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OWNER NAME: 1 w t 0,-5ADDRESS: /,g4' 69 Z Z L/ L"
CITY: ��t.e STATE: (1� PHONE: / 2-
PROPERTYIOWNER PERFORMING SEWER CONNECTION INSTALLATION? NO
IRCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR: ADDRESS:
CITY: STATE: PHONE:
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
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THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION : # OF BUILDINGS 1 X 50 .00 = ° v
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ 3- 4 G CD
APPLICANT ° , � \ s-
SIGNATURE -��'`-
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675