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1992, 11-02 Permit App: 92009612 Sewer
SEWER/PLUMBING PERMI1 APPLICATION FORM INFORMATION WORKSHEET JOB STREET ADDRESS: _5e c47)- CITY/STATE/ ,it CITY/STATE/ IP: OWNER: ./7yT.R.J"-" PHONE NUMBER: MAILING ADDRESS: 9D3- 1133 11�� tea- cAL2 �a PARCEL NUMBER: (St et) (City/state) (Zip) CONTRACTOR: � -� 9/ CZ? LICENSE NUMBER: PHONE NUMBER: MAILING ADDRESS: (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 Spokane County Department of Buildings West 1303 Broadway Avenue Spokane. WA 999Rn fcnoldaa_oc-7c