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1994, 10-25 Permit App: 94010648 Sewer 100421 SEWER thm, SEWER CONNECT ION PERMIT V APPLICATION FORM PLEASE NOTE: This application form must be filled out accurately and in its entirety, and signed, or a permit will not be issued. PROJECT INFORMATION Job address: Owner's name: /,s// retia`' . _ ,ems City: �l�'! � / City/State: _ , „, j 2,fia r Zip: 'f % > Zip: , 19_. Parcel number (if known): Phone: �} F 7/-g cs' ... WILL THE PROPERTY OWNER BE PERFORMING THE SEWER CONNECTION INSTALLATION?* Yes �No *If property owner is installing the sewer connection, they must first contact the UTILITIES DEPARTMENT for construction requirements before the permit is issued. CONTRACTOR INFORMATION Contractor (company name): State contractor license number: I-I 4 3 Con54-,r(Ac+,' )Y N S anki i2.3 4•Lr Business address: Utilities installers permit number: 118 t'-1 . \/G.1 l.P�11n/0 City/State: r-nIVA Zip: q q 2 0, Phone: ci - Bq („14 INTERIOR PLUMBING ALTERATIONS (if applicable)** Contractor (if different from above): Phone: Business Address: City/State/Zip: ** For plumbing reversal fee information, see reverse side of this form. FEE INFORMATION Sewer Connection: Number of Buildings X (times) $50 (per bldg) _ $ TOTAL FEE (One permit required for each separate building, shop,garage, etc., that will be connected to the sewer) APPLICANT SIGNATURE: (II' /Ii� /�, u/i4 Date: //,:3? 9/ Spokane County Division of Buildings West 1026 Broadway Avenue * Spokane, Washington 99260 * (509) 456-3675