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1994, 08-15 Permit App: 94007899 Plumbing ReversalSEWER CONNECTION PERMIT APPLICATION FORM qL,r7q0. g 115-10 ›? *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMITWILL NOT BE ISSUED. JOB ADDRESS: 7a 3 s. Q LJE 3 (IF KNOWN) PARCEL NUMBER: rig 41 CITY: S 1 © V\ N / : . ' STATE6" . ZIP CODE: OWNER NAME: p I \ \ \ IE S, --`t-- . ADDRESS: CITY •, 0 ` O I STATE: _,I(.)1\ . ZIP CODE: 1 PHONE NUMBER: paL\ 9 t i\ - 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: L , (i ;11,120 Rim, ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: STATE CONTRACTORS LICENSE NUMBER: UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? NO (CIRCLE ONE) INTERIOR ALTERATION BY: I 5 ! Gt )19�/ ADDRESS: / PHONE NUMBER: 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 r X 50.00 = S �•�' �� INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 = `L .C> > TOTAL PERMIT FEE DUE $ •C>C] APPLICANT SIGNATURE: DATE: SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675