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1993, 09-23 Permit App: 93008802 Sewer(-13 — Es3 op. Hit.LcasT ct3s- ?67 SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLEDUOUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE I S. OWNER NAME: C;` CITY: PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CIRCLE ONE) *IF PROPERTY OWNER INSTALLINGREQUIREMENTS BEFORE IPERMIOTNISCISSUEDUTILITIES DEPARTMENT FOR CONSTRUCTION STATE: ADDRESS: (IF KNOWN) PARCEL NUMBER: ZIP CODE: PHONE: 9,2 V- 21,-(Z-- CONTRACTOR: 1s1 CONTRACTOR e0N& 0.0N51-ek CnON ADDRESS: ?.O. 7P.O.Eiak f4 Z8 2. CITY: SPOKPd' WP- SggaI'4 PHONE: q2.8- 0559 STATE CONTRACTORS LICENSE NUMBER..: AQMSTCW`19P N1 UTILITIES INSTALLERS PERMIT NUMBER: 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 Ar# SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675 REGISTERED AS PROVIDED BY LAW AO©_o ,'e CONST CUNT GF NFR4 REGISTRATION NUMBER EXPIRATION DATE 01 A,RM STC=i192N1 0g/19/94• rFFECTIVr* t)ATt 08/21/81 APMSTRONG CONSTRuCTIW E� 0 6OX 14282 SIGNATOR is wk 992140282 Issu • BY DEPARTMENT OF L sR AND INDUSTRI