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1993, 09-23 Permit App: 93008773 Sewer • t I gns w �� 3s ---)5 93- 377if SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY L-Z AND SIGNED OR PERMIT WILL NOT BE ISSUED . pc pftE Gall 64/( IF KNOWN) ,,5„21.3 4 C t k PARCEL NUMBER: `1 ' 01/ JOB ADDRESS: �� ( 1 l CITY:S OAh NE. W STATE: ZIP CODE: OWNER NAME: \kt.N ADDRESS: i I I I (D \-+J C I : iq!J STATE: OA L • PHONE: 9 1 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (YESNO ONO *IF PROPERTY OWNER INSTALLNGSEWER, THEY MUST REQUIREMENTS BEFOREIRST PERMITNISCISSUEDUTILITIES DEPARTMENT FOR CONSTRUCTION TLC CONST�.UCT(ON ADDRESS: E. 1381( i2t" AVE CONTRACTOR: ZIP CITY: 5PokAIJz. LSA E= qqa 1(o PHONE: Gal -(0-11Q STATE CONTRACTORS LICENSE NUMBER . . : 11-CCO *1-O 7VI(.p UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS. 0 NO (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 . # OF BUILDINGS ( X 50.00 = >U , ©Cp SEWER CONNECTION (' INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS I X 35 .00 = -c) e) TOTAL PERMIT FEE DUE $ S5T-0 0 APPLICANT Le ini, ...., SIGNATURE -G SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 ( 509 )456-3675