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1994, 11-08 Permit App: 94011186 Sewer frAA Id ILLS / SEWER CONNECTION PERMIT APPLICATION FORM PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed, or a permit will not be issued. PROJECT INFORMATION Job address: Owner's name: S /G Z v t c-,,.,�, ,-- /I 6/7,/z-, City: Au-t.. City/State: Zip: 9 9 Z Z Zip: / Parcel number (if known): Phone: r WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION INSTALLATION?* Yes No *If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction requirements before the permit is issued. CONTRACTOR INFORMATION Contractor (company name): State contractor license number: AtI vNical S A cki v:e. A L‘A/A V A - JO P 5 Business address: Utilities installers permit number: PO 60)L 10 16 Ce,2, City/State: .,S0p,Kr .g. WA Zip: 9j c ZI i..4 Phone: Go.2 - B 5 or) INTERIOR PLUMBING ALTERATIONSLT— (if applicable)** Contractor (if different From -h�nCF,','� P11^1?P' _ I _ / ' I Business Address/ City/State/Zip:p ,,---- I ** For plumbing reversal fee information, see reverse side of this form. FEE INFORMATION Sewer Connection: Number of Buildings / X (times) $50 (per bldg) = $ e'! 3-73 TOTAL FEE (One permit required for each separate building, shop,garage, e. that will be connected to the sewer) APPLICANT SIGNATURE: 7 ' i - Date: /- / y y" Spokane County Division of Buildings West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675