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1993, 08-12 Permit App: 93006989 Sewer 65e7 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: fd ;"V ,417 PARCEL NUMBER: CITY: of STATE: /A.A ZIP CODE: q9 // t OWNER NAME: Jc/ S .i n e ADDRESS: r j 3 3 PI CITY: 5,D040,4 STATE: (AA- PHONE: PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? ar NO ( CIRCLE ONE) *IF PROPERTY OWNER INGSEWER , THEY MUST REQUIREMENTS BEFOREIRST PERMIOTNISCT THE ISSUED .TILITIES DEPARTMENT FOR CONSTRUCTION CONTRACTOR: ADDRESS: CITY: STATE: PHONE: STATE CONTRACTORS LICENSE NUMBER . . : UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES V (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 / SIGNATURE / / SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509)456-3675