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1994, 05-12 Permit App: 94004268 Sewer L G 1-12 ? SEWER CONNECTION PERMIT APPLICATION FORM 4i t`v i K,•6 �5t �� e 5 ti *THIS APPLICATION FORM MUST BE FILLED OUT ACCUTELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. (IF KNOWN) ADDRESS : J30s4 - /30/6 �, 3 /S - PARCLUMBER: CITY:$j0O4 4/I4 7 , STATE:_ ZIP CODE: OWNER NAME: DA-t/1d �t,l+L ADDRESS:(C a O . . 174-k CITY: ffk--Pi tJt STATE: JA _ ZIP CODE: 99 Zi) PHONE NUMBER: 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: TLC, �pns-hrin ADDRESS: I,3� I1.;, E7 . IZ 'We,. CITY: Si Qkv-A nP. STATE: v-IA- ZIP CODE: 619 1.--4 C. PHONE NUMBER: 92i1 - G,rJ(�,(7 STATE CONTRACTORS LICENSE NUMBER: 'I'' G G D * -- 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. SEWER CONNECTION * ft OF BUILDINGS / X 50. 00 = 5-0 . 00 INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35. 00 = TOTAL PERMIT FEE DUE $ 5?) . © O APPLICANT � ,SIGNATURE: r ( DATE: - 19,-9+ SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675