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1993, 09-09 Permit App: 93008136 SewerSEWER 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 PARCEL NUMBER' CITY: STATE�6Q�_ ZIP CODE: ADDRESS n �' O OWNER NAME= �y / CITY STATE PHONE: /� 7- PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO (CIRCLE ONE) RST T THE *IF OWNER SEWER, THEY MUST BEFORE PERMIT ISC UTILITIES ISSUED CONTRACTOR ARIYIST2AN6 C�DN-UCI•ION ADDRESS: ?0• Bo*, lyz67- CITY: SPOKANE. W P. T- qq a�4 PHONE= 9 '0559 STATE CONTRACTORS LICENSE NUMBER..: AeMSTG+hl9e�N1. UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS?(yE� NO lr�2 (CIRCLE ONE) INTERIOR ALTERATION WORK BY..: ((( ADDRESS CITY: PHONE: STATE= ZIP CODE= *ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC THAT WILL BE CONNECTED TO THE SEWER. = SEWER CONNECTION ............. c # OF BUILDINGS X 50.00 INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = �— $ g l� TOTAL PERMIT FEE DUE APPLICANT - SIGNATURE SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675