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1992, 06-05 Permit App: 92004057 Sewer
SEWER/ M M PERMIT APPLICATION FORM INFORMATION WORKSHEET JOB STREET ADDRESS: & 8 / 9 S , P t 12 0 \g --t) CITY/STATE/ZIP: MAILING ADDRESS: OWNER: PHONE NUMBER: --�—� _,(Street)L (City/state) (Zip) CONTRACTOR: /. T� AsT. LICENSE NUMBER: PHONE NUMB7 MAILING ADDRESS: /3 Y/6 E. /anti ,c-'700 $ 9 /E A . (Street) (City/state) / (Zip) PARCEL NUMBER: DESCRIPTION SEWER CONNECTION PLUMBING ALTERATIONS X EACH UNIT =AMOUNT X 50.00 = ,.Sb , 0 0 X35.00= SUBTOTAL $ EQUALS: TOTAL PEMIT FEE DUE _$ SIGNATURE Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675 q',2 -4t5 7