1993, 10-25 Permit App 93010259 Sewerf)l d� QchasXs
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST
TNBET FILE IEDSUOUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL
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CITYSc-) �)
OWNER NAME
CITY:S
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
(CIRCLE ONE)
*IF PROPERTY OWNER INSTALLINGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMITNISCISSUED.THE TILITIES
DEPARTMENT FOR CONSTRUCTION �
CONTRACTOR:
ToN
L.C. CSTZU,LT(O1 ADDRESS: E. 33E4(0 !Z Ave.
CITY: SPO.KAI��. IAA S T = \co PHONE: qa7
STATE:
(IF KNOWN)
PARCEL NUMBER:
ZIP CODE:
ADDRESS: 3 a As . lAivAti RS ' ' y
STATE:
PHONE: c $R 2 `•
STATE CONTRACTORS LICENSE NUMBER..: M-CCO At* 1'D'7G'I (.p
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES
(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 = C�
=
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 C
TOTAL PERMIT FEE DUE $ ti? ) - 0 a
r
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675