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1994, 04-27 Permit App: 94003618 Sewer -318 SEWER CONNECTION PERMIT APPLICATION FORM Veit � - 9/-1s *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KNOWN) JOB ADDRESS : /03-03 /4'71-G PARCEL NUMBER: CITY: J111r 4 STATE: .14. ZIP CODE: OWNER NAME .0/QR ( e2 /L ADDRESS: J CITY• 7/< /�� 1.�/STATE: - ZIP CODE: PHONE NUMBER: PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES NO (CIRCLE • ' *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: _rI.,.0 C(_115+r' ua _i_IL>n ADDRESS : 138 i b L .. 12 e-. CITY: �yny.yMP1- STATE: 1nJA ZIP CODE: CI9 2! (. PHONE NUMBER: 921 - STATE CONTRACTORS LICENSE NUMBER: -1 L,G G 0 * - 101 M (� UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES NO - 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. nn--�� SEWER CONNECTION - # '? [ OF BUILDINGS / X 50 . 00 = - 1 •©V INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 = ,.� TOTAL PERMIT FEE DUE $ 7 , C7c SPGNITURTC2 �_ � SIGNATURE:,.�'a�t.cn�Ck� CAL-cA-4.-&-ICKA/YL-4-----' DATE: SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675