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1994, 03-04 Permit App: 94001713 Sewer 5z13 .a - I3 01,4 ash SEWER CONNECTION PERMIT APPLICATION FORM IGS Z 3 *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. Fa(KNOWN) JOB ADDRESS : //063 J/OOS of 7 - PARCEL NUMBER: CITY:,SP()k in STATE: ) A ZIP CODE: RC(00( OWNER NAME: 3 r- War r ADDRESS : /0 /0 E CITY: 5 pO k/.F h . STATE: (A ) ZIP CODE: 9*R b(e) PHONE NUMBER: 41 -_-9/D qf q` 36,-;) PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO i' (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: Z ' c s+ co o,S4{u r-1-1011 ADDRESS: '7 El 8r-on rivJet.. / CITY: .,pr>.Krk STATE: N/A ZIP CODE: qq ZI ?. PHONE NUMBER: G I - q,q LL c STATE CONTRACTORS LICENSE NUMBER: Z - 099 -A1-1 UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES 10� (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 f X 50 . 00 = SO.00 INTERIOR PLUMBING ALTERATIONS : # OF BUILDINGS X 35. 00 = TOTAL PERMIT FEE DUE $ APPLICANT /\/OL4lO7t)SIGNATURE: DATE: -3 - Cl 711 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675