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1992, 10-15 Permit App: 92008905 Sewer
SEWER/PLUMBING PERMIT APPLICATION FORM- / C INFORMATION WORKSHEET �KT7 eOd / JOB STREET ADDRESS: c5 ' /' 06- ," ` Jt celet CITY/STATE/ZIP:t) • Leari • PARCEL NUMBER: / y,/ -a7 I . 19; 1061 PHONE NUMBER: 2O a2---- ' 2/'7`,— 09.5' n� Q- DFP VIA fsg,2s OWNER: MAILING ADDRESS: (Street) (City/state) (Zip) CONTRACTOR: COU&CHAtNE E)ICAYRTIDN LICENSE NUMBER. COtAeCCa'1E$-e7 PHONE NUMBER: 9a4-51465 MAILING ADDRESS: E. 1&4oa VAu:EvWAY Avg VERanaz WAr 99,057 (Street) (City/state) (Zip) DESCRIPTION SEWER CONNECTION PLUMBING ALTERATIONS SIGNATURE X EACH UNIT =AMOUNT X 50.00 = 1S'O X 35.00 = ..? --- 0 -ea SUBTOTAL $ X --7".57-a: EQUALS: TOTAL.c-6ue PEMIT FEE DUE =$ Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675