1992, 09-25 Permit App: 92008112 Sewer\vv v�1JU-JO / J
SEWER/PLUMBING PErMIT APPLICATION FORM (JAL\
INFORMATION WORKSHEET C:pS -
�, I
JOB STREET ADDRESS: G , I T1 CDUTH (L.(C
CITY/STATE/ZIP:
MAILING PARCEL NUMBER. "D, -...g I I a
OWNER; cADDRESS: l tLIE QH Ps7-1PHONE NUMBER:
CONTRACTOR. ►_mSne_O„Sreet) (City/state) (Zip)
LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street)
(City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=AMOUNT
X 50.00 =
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
_$
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675