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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 Jct'`.( ETT aPp c. a- \`57 -