1992, 10-20 Permit App: 92009100 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM Gj 2 5 . 1072
INFORMATION WORKSHEET
JOB STREET ADDRESS: " 2°0 1 i Nu$ee LME Z L-
CITY/STATE/ZIP: PARCEL NUMBER:
OWNER: PHONE NUMBER: Z« O�
MAILING ADDRESS: I
(Street) (City/state) (Zip) I ��
CONTRACTOR: LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00 =
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE =$
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675