1993, 11-16 Permit App 93011194 Sewer' 3<5 -/c 32-
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.
( IF KNOWN )
JOB PARCEL NUMBER : rsP4-4 • I gl )
OWNER NAME:
CITY:
n
STATE: ZIP CODE: �i'«)(/,‘
4)v-e_ ADDRESS:
STATE: PHONE: 9,71
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES d�0�
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE .UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUER.
CONTRACTOR: 1-A S CO R-S+(1.1 C.Air)C ADDRESS: 1 S 11 Va.l 1,_p Af (j�(/
CITY: -6{Jp]�Gllie, STATE: 14A PHONE: SoG - C126. Y�L'1-�-
` aG20(c,
STATE CONTRACTORS LICENSE NUMBER..: 145 LC I\! 1Z3 K
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES (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 = 5/./
INTERIOR PLUMBING ALTERATIONS: ## OF BUILDINGS X 35.00 =
00
TOTAL PERMIT FEE DUE $
APPLICANT
SIGNATURE /l
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675