1992, 10-28 Permit App: 92009480 Sewer SEWER/PLUMBING PERMI1 APPLICATION FORM Z , , ' 73INFORMATION WORKSHEET
JOB STREET ADDRESS: f1 / 2 C `S' 1;42,-r� ' eq� r � �
CITY/STATE/71P: , ' PARCEL NUMBER:
OWNER: /'2�-/� � /. f PHONE NUMBER:
MAILING ADDRESS:
(S t) �- (City/state) (Zip)
CONTRACTOR4 LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street) (City/state) (Zip)
X EACH �J a -)CA
DESCRIPTION UNIT =AMOUNT J� 0 aoS'pO
e2 L
(SEWER CONNECTION X 50.00 = `v_ O NSA \
PLUMBING ALTERATIONS X 35.00 = I,,��AQ -A y
SUBTOTAL $ �" S 1-"1
EQUALS: TOTAL ��V (i L
PEMIT FEE DUE =$ -�.\� l
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane. WA 999Rn (gn°\Aca 'c.'r