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1992, 06-18 Permit App: 92004502 Sewer
SEWER/PLUMBING PERMIT APPLICATION FORM INFORMATION WORKSHEET �Z-4 S02 012-4503 absq JOB STREET ADDRESS: / ,/ V g C/ /)4 ' v' /✓ WOL,FGeE-n-i 9 Z5- (038 CITY/STA E/ZIP:$ PARCEL NUMBER: ,G OWNE t,?// /2701./ PHONE NUMBER9a?Y tWOI MAILING ADDRESS: (Street) (City/state) (Zip) CONTRACTOR: H SatNSTaUCDON LICENSE NUMBER: HSCON .1E*I23KF PHONE NUMBER: 9210 MAILING ADDRESS: G.. IIBi'1 UAu..EywA1 AVE SPOk-ANE WA gcTa0(0 (Street) (City/state) (Zip) DESCRIPTION SEWER CONNECTION PLUMBING ALTERATIONS X EACH UNIT AMOUNT X 50.00 = X 35.00 = SUBTOTAL $ EQUALS: TOTAL PEMIT FEE DUE -�� SIGNATURE • y5I7/.1q , opilbZtu.N ITS( -TER-e6-C6 Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675