1992, 09-04 Permit App: 92007245 Sewerz
q25 3)(c.SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET aA
J
JOB STREET ADDRESS: $ 3 / 7 -4 A /�,.
CITY/STATE/ZIP: S//�,,,��o PARCEL NUMBER: /
OWNER: &OA/ r PHONE NUMBER: .PP -C)
MAILING,ADDRESS: JO✓�'
(Street) (City/state) (Zip)
CONTRACTOR: H 5 S CbRSTgUC110N LICENSE NUMBER: HS CAN -4.123KF
PHONE NUMBER: g2(o-8gto4
MAILING ADDRESS: G.. 1181'/ UALLEywAM AVE SPOk•ANE. WA ggQ04)
(Street)
(City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=AIytOUNT
X50.00=
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$ 5. ---ii Yr
c
Lk5 a a 1 I (POL.N \Lk co
L-1 /e
-
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675