1993, 02-22 Permit App: 93001005 Sewer--
SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS: S, 7d ( % I J1I� ,C n
c6
c�3l°es
33-100c
CITY/STAT,E/ZIP: SPo u P9t' PARCEL NUMBER:
OWNER: /fn Ao.e71.0 >4rev r PHONE NUMBER: 72_ SS .35/-S L
MAILING ADDRESS: S , 70 / &fi'4G% ,f S o' M'L w/7- 99z- iCo
(Street) (City/state) (Zip)
CONTRACTOR: LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street)
(City/state) (Zipj
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=AMOUNT
X 50.00 =
fDiCO
X35.00=
.5-C)a
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$ (Q1 GD
955 -42"
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675