1992, 11-30 Permit App: 92010476 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS: 0 4 S '
CITY/STATE/ZIP O ✓ C
OWNER:
Air o &Al cl
ova 40t176
PARCEL NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
n (Street) (City/state) (Zip)
(-- / LICENSE NUMBER: 't -CQ -0- k-ck /01M lo
�7 PHONE NUMBER: 9=2 7 p 7c ' 0
MAILING ADDRESS:/Y /� Jr, /Q4 0 AL Air •
(Street)
CONTRACTOR:
( ty/state) (zip)
I
cls-� ov--11
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X50.00=
- S & .00
X35.00=
SS. 00
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
��rr
=$ SS DO
ivy �C�
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675