1992, 06-18 Permit App: 92004504 SewerSEWER/PLUMBING PERMIT APPLICATION FORM 92,- LASOS
05(4
JOB STREET ADDRESS:
INFORMATION WORKSHEET
CITY/STA E/ZIP: PARCEL NUMBER:
OWNER. ••� e S e PHONE NUMBER:�� 7� cl A/��jj
MAILI ADDRESS:
(Street)
(City/state) (Zip)
CONTRACTOR: H r S &NSteUCYION LICENSE NUMBER: HSCON•IE*123KF
PHONE NUMBER: q 2l0 - 89 (014
MAILING ADDRESS: C. 1181'] UALLE'WAy AYE SPOkLANE WA clgaOlo
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=MOUNT
X 50.00 =
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
_$
�
6
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675