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1994, 03-25 Permit App: 94002447 Sewer 45374 . i315 " . CI4 . Z /41 Lr0 etaM'0 of SEWER CONNECTION PERMIT APPLICATION FORM G] j, L-1 8 Z I , ( .io3w 14,5 --31 . *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED (IF KNOWN) JOB ADDRESS : _� 3 e9 ..,. 4- t 7L-- PARCEL NUMBER: CITY: �1---- STATE: 9Z%' .. ZIP CODE: 99 0s" OWNER NAME: ;, ADDRESS: --z c-- ---P CITY: �7 STATE: ZIP CODE: PHONE NUMBER: f 2 2C 1 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: M5 pr'1n CDCCf-(v, V,-hon ADDRESS : 4) 1D. PX7X_ IL-1-2,F32.. CITY: ,5c�, ,ev), STATE: v./Ar ZIP CODE: g q 2 4. PHONE NUMBER: 9 c • O 55 cr STATE CONTRACTORS LICENSE NUMBER: A A M "(G-Ye 11 2-4 3- UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES (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. �J SEWER CONNECTION • # OF BUILDINGS X 50. 00 = ,..!; e . INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 = TOTAL PERMIT FEE DUE $ APPLICANT / 1ST"_ SIGNATURE:: DATE: .6 S /�, /� _--.`//��� SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675