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1994, 05-03 Permit App 94003873 SewerSEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN SIGNED OR PERMIT WILL NOT BE ISSUED. JOB ADDRESS: f (IF KNOWN) / 9: 'F 2 /.S- �/ r rw��a� ( PARCEL NUMBER: CITY: j> C7 r�G--2K STATE: A24 OWNER NAME : % J� I h.:- - Nv ✓ct CITY: a � 3g'i3 - in5 ITS ENTIRETY AND 6L 3 r J 453.2/, 4103 ZIP CODE: Z-41'76, ADDRESS: /�' / �- T r`'l STATE: Z/v/ ZIP CODE: Zci 6 PHONE NUMBER: - PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? EYEY S� NO TIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: r� 4,1 6= ✓ ADDRESS : CITY: STATE: ZIP CODE: PHONE NUMBER: STATE CONTRACTORS LICENSE NUMBER: 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 = gdb•4Q INTERIOR PLUMBING ALTERATIONS:# OF BUILDINGS / X 35.00 =\,.w TOTAL PERMIT FEE DUE $ ) SA4 APPLICANT SIGNATURE: DATE : 3 15- 0 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675