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1994, 06-01 Permit App 94004961 SewerSEWER CONNECTION PERMIT APPLICATION FORM 9 L/.--L f % *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. JOB ADDRESS: /Ogg/ c � t,{Y (IF KNOWN) /w ( `Ge���9C� C�� PARCEL NUMBER: CITY: �Of< Nr STATE: 04 ZIP CODE: 9920 Ce OWNER NAME: `GkQe / A /22 Li7ern� CITY: S oka/J e STATE: L-JA PHONE NUMBER: ?a?�9 3 - O CO 6 q ADDRESS: /Od// £ Dt,`F70iOcc1 C ZIP CODE: ` 7." 0 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? NO RCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: N/Gn/c/&lt//a £te&octl ;oA' ADDRESS: /Od// , O.^;{'l400c7 e,C CITY: .S/007'sc<n/ STATE: ix) / - ZIP CODE: / 90?O PHONE NUMBER: 5' S - /,5 s STATE CONTRACTORS LICENSE NUMBER: ZN/an e o 66, Ku,c.J 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 '# OF BUILDINGS X 50.00 = INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ APPLICANT SIGNATURE: DATE: SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675