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1993, 11-03 Permit App: 93010613 Sewer• 93.(op 3 cf3S- q53 SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KNOWN) JOB ADDRESS: :? /s ,O PARCEL NUMBER: CITY: STATE--eiit_ ZIP CODE: OWNER NAME: /G'� ADDRESS: CITY: STATE: PHONE: 9 (.1'37.Z� PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER, THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: ADDRESS: '?e CITY: ; STATE: 99�./e/ PHONE: 92A'es STATE CONTRACTORS LICENSE NUMBER. .:/%/?/VSi 4A,2.7)// UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES (CIRCLE ONE) INTERIOR ALTERATION WORK BY..: ADDRESS: PHONE: 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 = TOTAL PERMIT FEE DUE $ APPLICANT SIGNATUR SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675