1993, 04-16 Permit App: 93002564 Plumbing Reversal 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 .
KNOWN )
/ 4/ 9 // E / 6
JOB ADDRESS: PARCEL NUMBER
CITY: S/,'" c- STATE: C-04, ZIP CODE:
OWNER NAME: 2)0 2l 4 e. w Ls o.-\.
ADDRESS: /4/ 9// • /6
CITY: STATE: PHONE:
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: gu27`' lL>y Se cv/Ge� ADDRESS: a3 y67-54 C rP, v"-c 2c
CITY: o7r f 0'7?C- o.2 � STATE: (-4)61 , PHONE: c:9-
STATE CONTRACTORS LICENSE NUMBER . . : '2�' f '‹ /at N t3
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 $
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675