1993, 09-07 Permit App: 93008030 SewerS,--71/4Fo �
QT3- 8`a�
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY L—�7
AND SIGNED OR PERMIT WILL NOT BE ISSUED_ P„ / Add
JOB ADDRESS: oD(s) c ( S• G2 l (j.-?S
CITY : Spa(
PARCELI`NUUMBER : 4'5 /3 • d7lti
STATE: \4JY ZIP CODE:
OWNER NAME : - , �Cc,�,; ADDRESS :
CITY:
STATE: PHONE: c1-(4"1Y
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES C NO
(CIRCLE O E )
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER_
CONTRACTOR: rtts
CITY: SF,,--Ic <- 4
ADDRESS:
STATE: LLY-1 PHONE: `-1Z-L� x4
STATE CONTRACTORS LICENSE NUMBER..:
UTILITIES INSTALLERS PERMIT NUMBER:
nJ ti'' i Z3 IG F
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
DEPARTMENT OF LABOR AND INDUSTRIES
THIS CERTIFIES THAT THE PERSON NAMED HEREON IS REGISTERED AS PROVIDED BY LAW AS A
cop,ST COLT. GENERAL
LL4 L
REGISTRATION NUMBER
NSCONw,v1Z 1-
EFFc:CTTy: DATL
it 4 5 CONSTRUCTION
11817 t VALLYwAY
EXPIRATION DATE
05 / 05/ 94
05/Op/8o
99206
STATE OF WASHINGTON
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F625-052-000(3-92)