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1992, 12-08 Permit App: 92010775 Plumbing ReversalSEER/PLUMBING PERMIT APPLICATION FORM 2 `I� W INFORMATION WORKSHEET 2.t9 JOB STREET ADDRESS: 5.114 C --,(en CITY/STATE/ZIP: Scakc.ne LAPPA PARCEL NUMBER: MAILING ADDRESS: Souk OWNER: Ac slei PHONE NUMBER: 9 Zai - of 31 (Street) (City/state) (Zip) CONTRACTOR: H S &&N$ UC1 ror.l LICENSE NUMBER: HSCON ' Ia3 (F PHONE NUMBER: °126 -89104 MAILING ADDRESS: E 11811 VAu.EYI4/ Ave SPo krtnte 99x010 (Street) (City/state) (Zip) DESCRIPTION SEWER CONNECTION PLUMBING ALTERATIONS SIGNATURE X EACH UNIT =AMOUNT X 50.00 = X 35.00 = 3 S SUBTOTAL $ EQUALS: TOTAL PEMIT FEE DUE =$3S — Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675