1993, 04-27 Permit App: 93002981 Sewer 5a3U- a3c7 93- a ', S
SEWER CONNECTION PERMIT APPLICATION FORM Q 33 -Z(S
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF KNOWN ) yzst <—z3t '7
( ?)
JOB ADDRESS: ► 3-?o W PC-0, Z PARCEL NUMBER: Y5-22-"/, 2-347
CITY: 5 f e k ..A. STATE: u' ZIP CODE: g 11 1L/ 6
OWNER NAME: P 1 w R f-e-rsc r` ADDRESS: Su
CITY: STATE: PHONE: 612P —Y 4 7i
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ES NO
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ. PK
CONTRACTOR: ADDRESS: 14.14
CITY: STATE: PHONE:
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 0E5 ( 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' c,cm
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS _, X 35.00 =
TOTAL PERMIT FEE DUE $ 5—d
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675