1992, 10-20 Permit App: 92009101 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM 9.2. 5` /073
INFORMATION WORKSHEET
JOB STREET ADDRESS: 5 • 0 n I ( ��►'��` '� �� B — (,- 3 12- 9(0(
CITY/STATE/ZIP: PARCEL NUMBER:
OWNER: PHONE NUMBER: 1270
MAILING ADDRESS:
(Street) (City/state) (Zip)
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