1992, 09-28 Permit App: 92008139 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
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INFORMATION p�c -
WORKSHEET+n
JOB STREET ADDRESS: I J /O ( C? ,c Or
CITY/STATE/ZIP: Pc) . WG.- PARCEL NUMBER:
MAILING ADDRESS:
OWNER: c'�
PHONE NUMBER:
(Street)
(City/state
(Zip)
CONTRACTOR:TY, ('/e S LICENSE NUMBER: (Y'r JSc a 8) r Yt
i
44.1
n PHONE NUMBER:
MAILING ADDRESS: !2- //? 6 re) c civics cci
(Street) (City/state)
(Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X 50.00 = �/.
X 35.00 = r/
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$
S..kane County .epartment of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675