1992, 07-22 Permit App: 92005581 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION -WORKSHEET
Ct.a-55 (
Zs'7Z-?
JOB STREET ADDRESS: / 2 / Q ce- (;uIh r, ' C
CITY/STATE/ZIP:)(). U t XG PARCEL NUMBER:
OWNER: ex/ Y ic„..�Ce PHONE NUMBER: �a _ (4)(C.,,,,
MAILING ADDRE : g- // $ a, 6 y7)66-1 cu c 1. & ` tick)G
(Street) (Cit /state) (Zip)
CONTRACTOR: ( C's" 0 lei LICENSE NUMBER:—E12-1 PL3 C ,e9c l7 i i
PHONE NUMBER:
MAILING ADDRESS: E ( 1(.1.)a. /5 y)/ Lcl CLI S9 . co n,
. 7 �o2
(Street) (City/htate) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X 50.00 =
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
_$
i 04/AOI/7C
Spok. e County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675