1993, 12-10 Permit App 93011841 Sewer-(1 op
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)
PARCEL NUMBER:
JOB ADDRESS:
CITY
OWNER NAME
CITY:
STATE: PHONE:
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YCE
S
(SCLE ONE
Air
STATE:
ZIP CODE:
ADDRESS:
*IF PROPERTY OWNER INSGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMTTNISCISSUEDUTILITIES
DEPARTMENT FOR CONSTRUCTION
CONTRACTOR: la~C— CANSTzuCT1ON ADDRESS
E. L381(3 rZt" AVE
ZIP CA a. i Cn PHONE: G o7'j
CITY: 4o K A C- U3 PS S�A�E
STATE CONTRACTORS LICENSE NUMBER ..:-TZ--,CCO 7V41' O 7P I LD
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 =.5
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS
X 35.00 =
TOTAL PERMIT FEE DUE $6eI C)e)
APPLICANT
SIGNATURE
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675