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1994, 09-12 Permit App: 94008826 SewerSEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILLNOT BE ISSUED. (�[� � JOB ADDRESS: S . 0C//0 (j'l�/YYrr �.T J PARCEL NUMBER: CITY:)7Ccck� STA�TEE: le)/�- OWNER NAME:,UA€(!/ y 71-1 Ler- roet7(Y I STATE: 4% 4 - CITY: n PHONE NUMBER: / ® a? Q -- YoR E ! ZIP CODE: `9O?© ADDRESS : S. 390 co anoeitir ZIP CODE: 91? -7,1, c, PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CIRCLE ON *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR:2:n V4. -ADDRESS: /t17/( AFT poi .60eh JE/ CITY: SpL94., STATE: W14 ZIP CODE: Q? O -= PHONE NUMBER:/ - /SyO STATE CONTRACTORS LICENSE NUMBER: T KC (Q l e P• m `o6 s Lc.3 UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES O (CIRCLE ONE) INTERIOR ALTERATION BY: 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 = TOTAL PERMIT FEE DUE $ APPLICANT //%��/ /G C SIGNATURE: /rte( DATE: 9 `l_p SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675