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1993, 09-07 Permit App: 93008027 Sewer °1"Y n2 7 fleiVe ex-D © S 4 s SEWER CONNECTION PERMIT APPLICATION FORM g 3 J 4I V *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED . e" ( IF KNOWN ) c.157/✓- f JOB ADDRESS: 139 LO C it - PARCEL NUMBER: CITY: Sp C-^-e STATE: Gt^fl ZIP CODE: -Pitres 0044 L ( , 6 - OWNER NAME: LI Ff,�1-1u. ADDRESS: — CITY: STATE: PHONE: (32q--713c PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO ( CIRC ) *IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: 143 ADDRESS: 1M-7(`7 r f (C,� CITY: SeLkee.o STATE: u PHONE: 9 2Co 5(_9(-i STATE CONTRACTORS LICENSE NUMBER . . : N-S C,u ) - 12.3r: V UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES C NO (CIRCLE ONE ) INTERIOR ALTERATION WORK BY . . : ADDRESS: PHONE: CITY: STATE: ZIP CODE: *ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP , GARAGE , ETC n THAT WILL BE CONNECTED TO THE SEWER . SEWER CONNECTION : # OF BUILDINGS X 50 .00 = SC) INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35 .00 = TOTAL PERMIT FEE DUE $ S`-' 1. APPLICANT �' SIGNATURE SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675 DEPARTMENT OF LABOR AND INDUSTRIES THIS CERTIFIES THAT THE PERSON NAMED HEREON IS REGISTERED AS PROVIDED BY LAW AS A lsSf ONT , ,GENERAL ':.,2,'''','7;,:'W C1)ti 5y, * $ RE?GISTRATIONNUMBER;.- > EXPIRATION DATE,•. ` 54: 115 CON* 1�C3Kr 05/0S/ 4 ;. = r EF1 ECTj vE ; 0AtL 05/00/88 STATE OF WASHINGTON '`,1‘..';'‘':' `S CUNstRUCTION . , e %:118,17 E`-VALLEY4AY :, "SPOKANE•, 1JA 99?,(16 ti " It F625-052-000(3-92) l/�eVh�\leh�FR@kcl�h �ivtl��Tf�C�1C���12fPF.Kfi1Fe�Ml�2\���k\NerhhNVk1,��14��ec��1+4?e�c1e\ie��A "ie, _A'. 4