1992, 11-30 Permit App: 92010460 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET lTZ-S - Ll
JOB STREET ADDRESS: 5. ( (25- Ur)i oen, op_ (0q(00CITY/STATE/ZIP: Sp6�<<.� W PARCEL NUMBER: l
MAILING ADDRESS: sA me-
LD
�`�`T
OWNER: a,.,..rQ l.34}-k.Ai PHONE NUMBER: S2.C2- t 0 3
(Street) (City/state) (Zip)
CONTRACTOR: H S C.onc4-ruc bion LICENSE NUMBER: HSCatJ ; It. ►2.11(F
PHONE NUMBER: 92.16-85621-1
MAILING ADDRESS: E. I I2(1 UAu. /tAl ki (SUE• SPexAtoe., WA. (92.0(5
(Street) (City/state) (Zip)
X EACH OLD
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00= St)
PLUMBING ALTERATIONS X 35.00=
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE _$ So
SIGNATURE
S ane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675