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1994, 02-22 Permit App 94001369 Sewer6145 -/ SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED_ KNOWN) JOB AD DRESS: �``� `i Ck �A I'`') ©0A (* ,PARCEL NUMBER : CITY: S CcPkjSTATE: \O - ZIP CODE: OWNER NAME: -+i � R7 ADDRESS: OO ' CITY S O3 P 0 i� STATE: PHONE=C3).(0 1 wr PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (CIRCLEYES 0 *IF PROPERTY OWNER CONSTRUCTIONINSTALLING REQUIREMENTS BEFOREFIRST PERMITCONTACT UTILITIES DEPARTMENT FOR ISSUED CONTRACTOR: T�-C aNSTEUC.T(ON ADDRESS: E., 138((cj !2 ' AVE PHONE: Gad CITY: St�oklk)A -T i a \fin STATE CONTRACTORS LICENSE NUMBER..: LCCO * D 7T1 LP UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? YES (11(CIRCLE ONE) INTERIOR ALTERATION WORK BY..: ADDRESS: PHONE: 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 =0 • M INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 = TOTAL PERMIT FEE DUE $ \56,Dr) APPLICANT SIGNATURE 6 SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675