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1993, 11-15 Permit App: 93011099 Sewer r\--)pr cnsf-f C\ 3s- t ‘;, HiUc.eesr FORM C1 'O� SEWER CONNECTION PERMIT APPLICATION *THIS APPLICATION FORM MUST BE FILLEDOUTACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ( IF KNOWN ) / G/�' L'j A PARCEL NUMBER: JOB ADDRESS: `�/„ STATE ____ — ZIP CODE: CITY:S7 V . A ADDRESS: r /4 S. : OWNER NAME: /'��/� _ , A _ STATE:.,h'1� PHONE: - - CITY: � �► PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLE ONE T E *IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRSONTACISSHEDUTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT� IZ� AVS TL@ C�NST�uC,T�oN ADDRESS: E 381 CONTRACTOR: Ga'j CITY: STAfiE= S I(42 PHONE: STATE CONTRACTORS LICENSE NUMBER UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) INTERIOR ALTERATION WORK BY . . : PHONE: ' ADDRESS: STATE:_______ ZIP CODE: CITY' *ONE PERMIT REQUIRED FOR EACH THE SEWER. BUILDING , SHOP , GARAGE, ETC THAT WILL BE CONNECTED TO # OF BUILDINGS �� © X 50.00 = 0 SEWER CONNECTION ' INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = TOTAL PERMIT FEE DUE $ APPLICANT / I SIGNATURE `' SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675