1992, 06-03 Permit App: 92003978 SewerSEWER/PLUMBING PFRMriT APPLICATION FORM
INFORMATION WORKSHEET
/1 /v im
JOB STREET ADDRESS:
CITY/STATE/ZIP:Spoks hie. 4/N4 h - 9 "'PARCEL NUMBER:
OWNER: c cit/194 PHONE NUMBER.
ADDRESS: .S' /1 In i1-2 4..Liel-tA-- /2 ,
(Street) (City/state) (Zip)
CONTRACTOR: LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
q a ---3c178`
MAILIN
(Street)
(City/state)
(Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=AMOUNT
X 50.00 =
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
(AIT FEE DUE
_$
So
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675