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1994, 05-10 Permit App: 94004155 SewerSEWER CONNECTION PERMIT APPLICATION FORM 5®j *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. (IF JOB ADDRESS: 36//) . LC)DQ4 rLk-(4-C-±-PARCELOWN) NUMBER: CITY: 3p()kA }lSTATE: LL)A ZIP CODE: ' 9 / R. OWNER NAME : 1 ► (m A-0 j n-- �-! I �2 . (2 22:6- u aC-1- 9 ADDRESS : CITY: ) J()/ 3. )J.4) STATE: (,U v ZIP CODE: ' 1 D / 1,-LPHONE NUMBER: q cf 01j 0 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: Z--12)e-s-1- i'0li-A-{ u r -or ADDRESS: 7€ sBrbG r.I-u1Gt›./ CITY: �,f�n. �,lll STATE: WA ZIP CODE: qC7 I PHONE NUMBER: F 9 j - q� STATE CONTRACTORS LICENSE NUMBER: Z p ,S r _ 91 AH UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE) INTERIOR ALTERATION BY: ADDRESS: CITY: PHONE NUMBER: 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 = 5-7) (T? INTERIOR PLUMBING ALTERATIONS:'# OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ C%, (rt APPLICANT SIGNATURE: 7/ � DATE: SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675