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1992, 12-02 Permit App: 92010534 Sewer
EWER/PLUMBING PERMIT APPLICATION FORM �--� 20 If SEWER/PLUMBING WORKSHEET ak5A JOB STREET ADDRESS: -_ PARCEL NUMBER:__________--- G� CITY/STATE/ZIP: �-'�� �.J�' MAILING ADD'ES • PHONE NUMBER: OWNER: _ (Street) (City/state) (Zip) i, �y S AGTIV E LICENSE NUMBER: Al-i-44k R"� -_1-( IT CONTRACTOR: -- PHONE NUMBER: 4?,R" 500 {; 1141 stow S PekAme WA -Rai MAILING ADDRESS: a (Street) (City/state) (Zip) IMMI =AMOUNT DESCRIPTION X50.00 = �5201• lQs�-- SEWER CONNECTION _� PLUMBING ALTERATIONS X 35.00= �-o( 1-u -k--\-)3_, SUBTOTAL 1111111111111 (� EQUALS: TOTALMS0111 r PEMIT FEE DUE SIGNATURE Spokane County Department of Buildings West 1303 Broadway Avenue Spokane,WA 99260 (509)456-3675