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1993, 11-10 Permit App: 93010883 Sewer�i3-10�3> SEWER CONNECTION PERMIT APPLICATION FORM 8S *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. JOB ADDRESS : 3 S S SIA Vkel a 1A1 h CITY: (IF KNOWN) PARCEL NUMBER: STATE: Wn ZIP CODE: 99aDV, OWNER NAME : C rx tre a 1r 1ADDRESS : CITY: STATE : PHONE: qay -1 a eoo PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES1�0 ( CIRCLE ONE ) *IF PROPERTY OWNER' INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED.. CONTRACTOR : N E S CO (,-libn ADDRESS : 1 t S 1'1 vU-11���(__ CITY: -5FoXCpl1le. STATE: PHONE: SY% • Cl 2A2 • Q%�� �G 2 STATE CONTRACTORS LICENSE NUMBER..: i-� 5_( f 0 f...j - 12.3 KK UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES N0 (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 It OF BUILDINGS � X 50.00 = iD,0 O INTERIOR PLUMBING ALTERATIONS: 0 OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ 50,0 0 APPLICANT SIGNATURE SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675 4 4