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1994, 03-10 Permit App: 94001953 Sewer145 n3. 2 lI I-I,(65-ke% SEWER CONNECTION PERMIT APPLICATION FORM qL/ c153 JOB ADDRESS: CITY: OWNER NAME: CITY: Lit 432- *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. 2��%c��.� PHONE NUMBER: STATE : (IF KNOWN) PARCEL NUMBER: ZIP CODE: f� ADDRESS: STATE: ZIP CODE: 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: f ^S`{e�} Y�� } �7,�C.-f r) ,�-(N(=I'10. 1 ADDRESS: -PO . PXDX- CITY: Sr-)-k, `J STATE: VJA- ZIP CODE: qc 2J 4- PHONE NUMBER: 1 2 STATE CONTRACTORS LICENSE NUMBER: AAt•A Ci 161Z.14 i UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES (IQD� (CIRCLE ONE) INTERIOR ALTERATION BY: ADDRESS: CITY: STATE: PHONE NUMBER: 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 = INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ s �l APPLICANT SIGNATURE:; DATE : ,7 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675