1993, 04-06 Permit App: 93002194 Sewer Gas-
Q 04
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 . JC(Z`s1
-5� g.
/ / ( IF KNOWN )
JOB ADDRESS:A/ /✓7 g ��1 PARCEL NUMBER: Li 5 2-te f. 80 5
CITY: ,_ 0tp)( STATE: 14/.,54 ZIP CODE: 5 9 240G
OWNER NAME: U,2491 10'//e, ADDRESS: /‘/ / ItgrCP ..q.oi7 4
CITY: 5/40/ -- STATE: I/'' PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES 491)
( YISCLE ONE)C
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ.
CONTRACTOR: �D'WS CSX/�4'uc. ADDRESS: 97 /s ��.*
STATE: //. 4j PHONE: 7� - ----
STATE CONTRACTORS LICENSE NUMBER . . : �/�' /9 S C 2 4/ c' 7
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
E ...,SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675