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1993, 04-05 Permit App: 93002130 SewerSEWER CONNECTION PERMIT APPLICATION FORM 2I *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. 1 '(IF KNOWN) : V r c �, - 5c� 6-02 _ 7 JOB ADDRESS : `�� l�' PARCEL NUMBER CITY ' STATE: 0D.. ZIP CODE: \� c --,OWNER NAME: i 'or'..� Q.(��ADDRESS : CITY:��1� STATE 'C� PHONE : 9 8 — 8Coo ack PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CIRCLE 0 *IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED., CONTRACTOR: \c''"{�'~ tck ADDRESS : T 1 ( \ A r: N CITY: c ., STATE: a. PHONE: 2 -CP ---.`"5 STATE CONTRACTORS LICENSE NUMBER.. UTILITIES INSTALLERS PERMIT NUMBER: V ©M 9 04 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 ` rs - Vexctde5F SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675