1992, 09-28 Permit App: 92008141 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET 5-97 -9
JOB STREET ADDRESS: t\C)? 4- 6 -'-Th r F c) r
CITY/STATE/ZIP
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P
MAILING ADDRESS:•ij3L -jrdrA I Cti)/{• (.X.,1 4
OWNER:`J37� /lJ;vC i((..ti PHONE NUMBERCara.-"�
)
(Street) (City/state) (Zip)
CONTRACTOR: Y, p/c S LICENSE NUMBER: (Y,' /vco da'm h
nn PHON€ NUMBER: _ 8.
MAILING ADDRESS: G- //_U 6 re C O GJ Com/ tvv- (.0 C
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATUR
X EACH
UNIT
=AMOUNT
X50.00= 4,..---
/X35.00=
X 35.00 =//
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$
okane County Department of Buildings
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West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675