1993, 08-24 Permit App: 93007152 Sewer 2--
935 _631
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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KNOWN )
JOB ADDRESS: 31► \ X131 \ (-. �\� PARCEL NUMBER:
3
CITY: SPC? STATE: �� ZIP CODE: '9;z.16
OWNER NAME: � C•PevN- ADDRESS:
CITY: .5d90 STATE: WG PHONE: 9? - 1a l
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR� CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.
CONTRACTOR: l, Ct vv\AeK-S D 1 (A7K- ADDRESS: <-5 / 36;7 <k GnV eV\ e
CITY: Se0 STATE: fir` PHONE: cls )
STATE CONTRACTORS LICENSE NUMBER . . : 1-1CA-M M
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES 4 ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . :
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
•
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC M
THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION # OF BUILDINGS l X 50.00 = O a D
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $
APPLICANT SIGNATURE Jog
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
W T 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
P.3-21-'93 TUE 09:02 I17:TUh iff ER LUCRT I DN. TEL 110:206 239 5461 1151E P17.11
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