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1993, 10-29 Permit App: 93010477 Sewer 6(3 - /©LI77 q3S SEWER CONNECTION PERMIT APPLICATION FORM 43 - ld)(476 *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED . ( IF KNOWN ) JOB ADDRESS: 3 cP/S— E.o . PARCEL NUMBERPARCEL : CITY: i STATE: t)q. ZIP CODE: 9Y,2?4 OWNER NAME: 4LJ4'v WI/IL) ADDRESS: CITY: STATE: PHONE: 7d/- -.7c2 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (� ( CIRCLE ONE ) *IF PROPERTY OWNER INSTALLING SEWER , THEY MUST FIRST CONTACT THE .UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: 4 S aO f1.5+(UA 6-1-iron ADDRESS: I t S 1'1 e. V0.1 ley ni CITY: -6iCAZ.CA E- STATE: V4A PHONE: SERI • q26 • $G1614 aq 20(9 STATE CONTRACTORS LICENSE NUMBER . . : ISS CON )k-sF 123 -c UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO ..(CIRCLE ONE ) INTERIOR ALTERATION WORK BY . . : W'=4"-", ( .4.rr,e ) 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 = 00 INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS / X 35 .00 = oSSJ TOTAL PERMIT FEE DUE $ APPLICANT SIGNATURE ( SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675