1993, 06-17 Permit App: 93004691 Sewer \144rii (4NLSY\4 14-c,
CJI lc) L \ 3
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 .
PARCELI<NUMBER:NOWN ) �� � , I `7 /3
JOB ADDRESS: �L
CITY : STATE: (Op, ZIP CODE:
OWNER NAME: rr\94skre-
ADDRESS: - t oP "'i
( L
STATE: L �
` PHONE: q `f V&(7-
CITY:C'l
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( CISCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
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
THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION # OF BUILDINGS X 50 .00 =
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPL ANT
SIGNAT /� I� T
- ° eK •NE COUNTY DEPS TMENT OF BUILDINGS
WEST 102: =' :ADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675