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1993, 04-22 Permit App: 93002799 Plumbing Reversal;-Ael° 3 — Z7( -, s- 2s q3�.�9 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. JOB ADDRESS : ( S {..lc, CITY: OWNER NAME: Jnr. (IF KNOWN) PARCEL NUMBER: STATE:h ZIP CODE: ADDRESS: CITY: STATE: PHONE: q)zk - g 7 `i� PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (44-- N� (CIRCLE NE) *IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUEQ. CONTRACTOR: 1-1t CITY: ^,6l(_(r� ADDRESS: !;t)7, C ��.) STATE: t -c PHONE: 9 2<<9L! STATE CONTRACTORS LICENSE NUMBER..: -/ - S CciJ UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE) INTERIOR ALTERATION WORK BY..: 1-1 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 = CC' INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS ! X 35.00 = 'S TOTAL PERMIT FEE DUE $ S -- APPLICANT APPLICANT SIGNATURE SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675