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1994, 05-17 Permit App: 94004431 Plumbing Reversal SEWER CONNECTION PERMIT APPLICATION FORM 1L LP) *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BES ,ISSUED. >8,&J //�,e/L/( (I F KNOWN) JOB ADDRESS : o}, / (/ / // PARCEL NUMBER: CITY: ^A �� _ STATE: ,44 , ZIP CODE: OWNER NAME: Gil ADDRESS: CITY: © STATE: ZIP CODE: PHONE NUMBER: g 7 a _7Q r PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO (CIRCLE ON ) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: P L S ADDRESS : 11E; 11 CITY: c.Seo.Kl Pi STATE: WA ZIP CODE: PHONE NUMBER: G 21v - STATE CONTRACTORS LICENSE NUMBER: (7/J1 I2--3 -kf UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) INTERIOR ALTERATION BY:_mss ( �-1-/AJA,•L!°!° ",4,_- 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 = �s - TOTAL PERMIT FEE DUE $ 25 - APPLICANT • Y SIGNATURE: I/ . d ,�. i I I� i7/ DATE: -s ��/9 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675