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1994, 01-20 Permit App: 94000486 SewerSz1 Rests 53 SEWER CONNECTION PERMIT APPLICATION FORM PHIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY NND SIGNED OR PERMIT WILL NOT BE ISSUED. JOB ADDRESS: 2C <'s CITY: / C <'c<c <£ STATE : f1 OWNER NAMEC 7 / ( [ chi C /( J CITY: C,��`a� STATE: l �� PROPERTY OWNER PERFORMING SEWER 0 (IF KNOWN) PARCEL NUMBER: ZIP CODE: (f/-e- �/ Jc PHONE : /2 j - i' J CONNECTION INSTALLATION? E NO 'CIRCLE ONE) :IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.. CONTRACTOR (rk /c ? e' Y C t 'ADDRESS : PHONE : 7 CITY: STATE: STATE CONTRACTORS LICENSE NUMBER..: UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES INTERIOR ALTERATION WORK BY..: ADDRESS: PHONE: CITY: STATE: ZIP CODE: NO (CIRCLE ONE) *ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC THAT WILL BE CONNECTED TO THE SEWER. SEWER CONNECTION INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 50.00 = # OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ 0 APPLICANT SIGNATURE 7 • SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675