1993, 08-20 Permit App: 93007298 SewerSEWER 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: QC Qt C0 S PARCEL NUMBER :
CITY:
OWNER NAME: -lUun�o l�
STATE: iA ZIP CODE:
ADDRESS: — SL r. 9 -
CITY: STATE: PHONE:
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PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES N-CD
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR: ADDRESS: 1 (Ei? ) 04 tU¢1, ,1
CITY: STATE: ^(' PHONE G?.C'
STATE CONTRACTORS LICENSE NUMBERlc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO \ (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE:
*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 (5O9)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
STATE OF WASHINGTON
H & s CONSTRUCTION
1.181? E. VALL -Y, AY
SPOKp, 4E
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F625-052-000 (3-92)