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1992, 12-24 Permit App: 92011174 Sewer
SEWER/PLUMBING PERMIT APPLIQATION FORM Z'''/#7C/INFORMATION WORKSHEET JOB STREET ADDRESS: /-" y�' 1 7 — '-'-----'feel Ct: Z") CITY/STATE/ZIP: �_ 0 - (1.-)e? - PARCEL NUMBER: l OWNER: L y1 - ,g)-c— PHONE NUMBER: 9c2<—g', 1-7/ MAILING ADDRESS: ��----)- '___:, (Street) (City/state) (Zip) CONTRACTOR: COtAKeHAIt,1E EXC PcTiON LICENSE NUMBER: Cou .CCA#184-07 PHONE NUMBER: q6)4-54485 MAILING ADDRESS: 6. 1! 402. VAt.IEyWR.t AVG' VOZNE)ALE wAr CR037 (Street) (City/state) (Zip) X EACH DESCRIPTION UNIT =AMOUNT (SEWER CONNECTION X 50.00= e.) '?- PLUMBING ALTERATIONS X 35.00= SUBTOTAL $ D ' EQUALS: TOTAL ek-e) PEMIT FEE DUE =$ (21,(- ��SIGNATURE Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675