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1994, 01-20 Permit App: 94000489 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. qg-L-1-gq 9145--55- JOB SS--S S JOB ADDRESS: /% )2<r CITY: �� �Ci �5� STA -1:E: a C? Y'2/1'('1" OWNER NAME <<'� LncZ � CITY:VJC -J-J ADDRESS: STATE: /t-4-1 (IF KNOWN ) PARCEL NUMBER: ZIP CODE: /-'qD� '7 PHONE: exic.cry/ PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ¥ES IRCLE ONE) IIF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT F CONSTRUgION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOF': (' 1 `c 6(-2 `i /(1 c,'�"C` e'�� DDRESS : � CITY: STATE: PHONE:r 4-7- 2 2" STATE CONTRACTORS LICENSE NUMBER..: 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 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675 n