1993, 05-03 Permit App: 93003140 Sewer -.0K°. i . q ,...--)_ ILk
SEWER CONNECTION PERMIT APPLICATION FORM a4
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED . ' ah CIl
r ( IF KNOWN ) y5a-73 Q--1
JOB ADDREB _ ___ PARCEL NUMBER:
CITY : STATE:ae4 ZIP CODE: ' �/�
-J) ,
OWNER NAME:
ADDRESS: S //2i?/
CITY: STATE: PHONE: < ,2 ---s /
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO
( YISCLE ONE )
*IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED .
CONTRACTOR: PtiMS`v2AN0.ONS`TP-tlCTioN ADDRESS: ?0. BOX 14282.
CITY : SPOKAN .- WIN, ST Glgaiy PHONE: g213'0559
STATE CONTRACTORS LICENSE NUMBER . . : AQMSTGvi`lq N1
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : -- -7-4_,
a:1ADDRESS: 3��c/ . PHONE: �2 'e7 6---V2`
CITY: (9 STATE * ZIP CODE: 52 72 2
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER .
SEWER CONNECTION # OF BUILDINGS / X 50 .00 = ,_!c
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35 .00 = 3-S`
TOTAL PERMIT FEE DUE $ ' `
APPLICANT /`f )
SIGNATUR (�
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675