HomeMy WebLinkAbout1993, 06-22 Permit App: 93004933 Sewer 401A01,0 6\NV 139
P5[v_ 53
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE
FILLED
LEDUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOTBE
( IF KNOWN )
JOB ADDRESS: /(0 Ye E. 3 . A/c/ . PARCEL NUMBER: r3ZX.:) • 5,.3
CITY: 5;0(4)��
STATE: _______ ZIP CODE:
o c Li �l N. /1/D
OWNER NAME ZADDRESS= D ��� /
CITY: D /If/ STATE: (.11 ' PHONE: 1-71 , -777!
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (YES NO
.NO
*IF PROPERTY OWNER INSTALLING EQUIREMENTS BEFORE,
IPERMIOTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION R
CONTRACTOR: TLC CoNsTeucTioN ADDRESS: 6 , 1381(0 )2t''' PAVE
CITY: SpoKPcNF WA
QE-: ciciR I(o PHONE: G21- (01100
STATE CONTRACTORS LICENSE NUMBER. . : "TL.CCasit1.01 Ml'
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
(CIRCLE ONE)
INTERIOR ALTERATION WORK BY . . :
PHONE: '
ADDRESS:
CITY: `
STATE:_____-_ ZIP CODE:
*ONE PERMIT REQUIRED FOR
TEEACH
CHESEPARATE BUILDING , SHOP , GARAGE, ETC
THAT WILL BE CONNECTED
SEWER CONNECTION '
# OF BUILDINGS X 50 .00 CO=�9•
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35 .00 =
TOTAL PERMIT FEE DUE $ SrQO
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675