1993, 10-01 Permit App: 93009158 Sewer •
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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 .
�l ( IF KNOWN )
JOB ADDRESS: l JAI L J C PARCEL NUMBER:
CITY: 5poic.`— STATE: WO ZIP CODE:
OWNER NAME: G --- 1141 ADDRESS:
CITY: STATE: PHONE: 721
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: 1-1" ADDRESS: 811 ` v``i 1 1
CITY: `),,k_,-..s STATE: V�� PHONE: 2L yy"`
STATE CONTRACTORS LICENSE NUMBER . . :
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (2 ;__;) (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 $ S `,
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APPLICANT
SIGNATURE I -
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
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DEPARTMENT OF LABOR AND INDUSTRIES
THIS CERTIFIES THAT THE PERSON NAMED HEREON IS REGISTERED AS PROVIDED BY LAW AS A `
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REGISTRATION NUMBER EXPIRATION DATE
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EF c-CTIYT ATS, C5/Oa/ 'a STATE OF WASHINGTON
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4.1817 E. VALL .YIwAY
Si'OKA: E 6A ' 9920.6
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