1992, 06-03 Permit App: 92003966 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS:/ (9 / 3 J, 6 -le I,/ 11
CITY/STATE/ZIP: � 6/"�Q's P CEL NUMBER: D T 7—
MAILING ADDRESS: / r -3 5', v �K_/�n 9'Z Q Co
(Street) (City/state) (Zip)
CONTRACTOR: LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street)
(City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE �^
X EACH
UNIT
=AMOUNT
X 50.00 =
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE„
=$
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675
f39-,4. a _ 390-7
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