1992, 08-17 Permit App: 92006503 Sewer9244'sd3
SEWER/PLUMBING PERMIT APPLICATION FORM g:A./.L
INFORMATION WORKSHEET
q2- G5oq
JOB STREET ADDRESS:
CITY/STATE/ZIP.
OWNER:
MAILING ADDRESS:
(Street)
PARCEL NUMBER: �/
PHONE NUMBER: 9,2 V" O 91�
(City/state) (Zip)
CONTRACTOR:Coue.CHA-InIE EXCAVATioN LICENSE NUMBER: aOUCCC yt181i2'1
PHONE NUMBER: q 4 -54485
MAILING ADDRESS: E. i (pLoa UA-u.eyWA y AVE YeeAEALE WA X39037
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X 50.00 =
X35.00=
.7_.
c`e
SUBTOTAL
$ r
C'?
EQUALS: TOTAL
PEMIT FEE DUE
=$
4f4e./Cd6L--"e-L.,_,
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675