1992, 07-08 Permit App: 92005069 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM OW caAT
INFORMATION WORKSHEET UL j ID (N-D6
JOB STREET ADDRESS: PARCEL NUMBER:
CITY/STATEIZIP: ' ? z ° � _ --' � 215/ rt 07
o -fes -i—A-4 �� rm.:MAILING ADDRESS: PHONE NUMBER: .+
OWNER: (Street) (City/state) (Zip)
CONTRACTOR: ? ti L a LICENSE NUMBER:
PHONE NUMBER: 2 D
�9 z/L
(Street) � •8 , 'x •1 ��
MAILING ADDRESS: - "" (City/state) (Zip)
ISM
DESCRIPTION =AMOUNT
1111111111111111111
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00=
11111111111011111111
SUBTOTAL 011111111111111111
EQUALS: TOTAL
PE T FEE DUE
SIGNATURE A
S•• ane County Department of Buildings
West 1303 r•.dway Avenue Spokane, WA 99260 (509)456-3675