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1994, 10-20 Permit App: 94010470 SewerSEWER 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: � 5 ci 17- rict� (IF KNOWN) PARCEL NUMBER: CITY: SIrr)(A CUAQ STATE: LA- ZIP CODE: OWNER NAME:V1ZCe Li i.)00SSSc ADDRESS: ,515 KO5J2k.VD<ll A CITY: S���a.� STATE: LA ZIP CODE: /gZOS PHONE NUMBER: eOel-c1,ir3-14,5 3 7 --- PROPERTY PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES lU (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: (�VLPl.nel JWQGI,V4 ADDRESS: CITY: Q STATE: L.J/ ZIP CODE: PHONE NUMBER: °I 9 9-t.) 13 STATE CONTRACTORS LICENSE NUMBER: UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES �O (CIRCLE ONE) INTERIOR ALTERATION BY: 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 X 50.00 = INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ DATE: SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675