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1994, 07-17 Permit App: 94006672 Sewer -P : �...._\ SEWER CONNECTION PERMIT APPLICATION FORM ‘, Lt1L. *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. /l (IF KNOWN) JOB ADDRESS : /0-c-/)/5 .': Y 7A PARCEL NUMBER: CITY: S( © �.�gAI,4E" STATE: (i() ZIP CODE: OWNER NAME: C6"4'O/E'�.E C .p A/'/1) ADDRESS: CITY. / /1if�/ STATE: A.)19.- . ZIP CODE: PHONE NUMBER: ,P.2>- 6 r 3,sr PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES C:i2) (CIRCLE *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: ADDRESS : I3< i t , • 12 A-vG. CITY: -Sal�n r P - STATE: '4A- ZIP CODE: q9 PHONE NUMBER: 12,1 - STATE CONTRACTORS LICENSE NUMBER: -t !1 G G D - - 1�5 I M ( UTILITIES INSTALLERS PERMIT ,NUMBER: INTERIOR PLUMBING ALTERATIONS? YES /C7101'N. 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 l X 50. 00 = INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 . 00 = TOTAL PERMIT FEE DUE $ -`C. On SPGLITURE 9 /t.� SIGNATURE:. 2'-DATE: l / 7y `/7 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675