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1994, 10-24 Permit App: 94010588 Sewer CM3 SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRED SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KNOWN) JOB ADDRESS : S jJ Z / JLC <r4 6 PARCEL NUMBER: CITY: jPU 2/it-/v,, /6-/ STATE: ZIP CODE: OWNER NAME: P--/7j/. ) ADDRESS: CITY: �"' — STATE: C-V ZIP CODE: PHONE NUMBER: 5 V - Z / 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: 4 I vJaT, Ac.4 v e- ADDRESS: ..1)J . � I►-I- (,2, CITY: �4er,VIA 1.0 STATE: WA ZIP CODE: go9,0-I- PHONE NUMBER: 612-1- 1:36(c)() STATE CONTRACTORS LICENSE NUMBER: A L.W 0V4 A 1q7(- UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) INTERIOR ALTERATION BY: ADDRESS : PHONE NUMBER: CITY: 5;) ,r/Ve- STATE: V//04 ' ZIP CODE: rde *ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL BE CONNECTED TO THE SEWER. SEWER CONNECTION • # OF BUILDINGS X 50. 00 = S`0 INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 = TOTAL PERMIT FEE DUE $ 5-0 -- w- APPLICANT 0 "APPLICANT SIGNATURE: -00 DATE: /0/ `1/r7 SPOKANE COUNTY. DEPT, OF BUILDINGS WEST 1026 BROADWAY. AVENUE.' A SPOKANE, fir A 99260'• /4 77T O �r fI