1993, 03-12 Permit App: 93001444 Plumbing ReversalSEWER/PLUMBING PERMIT APPLICATION FORM 3. 1 tiU 3
INFORMATION WORKSHEET 3
513
JOB STREET ADDRESS: . I 7-2_(..)
.Lk( C
CITY/STATE/ZIP:, unit PARCEL NUMBER:
MAILING ADDRESS: — St, -
cy2D--
OWNER:
PHONE NUMBER: q 1'4 -(s?
(Street) (City/state) (Zip)
CONTRACTOR: i-14 S LICENSE NUMBER: 14- u 1 icf
MAILING ADDRESS: C 118r?
(Street)
PHONE NUMBER: 5 .2-6?- Y4 iso`(
(City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
SEWER
=AMOUNT
X50.00=
S -
X 35.00 =
5
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$
?-S-
-S
pokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675