1992, 08-04 Permit App: 92005798 SewerSEWER/PLUMBING PERMIT APPLICATION FORM 0\ �Z_ 5 a I
INFOAMATION WORKSHEET
JOB STREET ADDRESS:
CITY/STATE/ZIP: S 4-5 kve�
OWNER:/f•'//c/ pr.
MAILING ADDRESS:
G
CONTRACTORA S. C
MAILING ADDRESS:
(Street)
PARCEL NUMBER: ed PHONE NUMBER: Pol 0) (i/
(City/state)
LICENSE NUMBER:
PHONE NUMBER:
L aEr-
(Street)
(City/state)
(Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNAT
X EACH
UNIT
=AMOUNT
X50.00=
St
X 35.00 =
?
5
SUBTOTAL
$
EQUALS: TOTAL
P,EMIT FEE,.DUE
=$
j
�5'
4 / ✓_.i
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675
y.52a033