1993, 03-04 Permit App: 93001231 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM c\35, 5 1
INFORMATION WORKSHEET ^�
JOB STREET ADDRESS: /S'2 C/ S U 1Ji 0-e(" S i Ty C13--
CITY/STATE/ZIP:SPOkgW e W tt 99)20(, PARCEL NUMBER:
OWNER: S%if/t3 w f1`13 PHONE NUMBER: a c/& ? 4'
MAILING ADDRESS: � 7 '
(Street) (City/state) (Zip)
CONTRACTOR:L Y i?..iu LICENSE NUMBER: !TE P.cEs A/0.8 1 TB
PHONE NUMBER: 90?9 'tl /S'S'
MAILING ADDRESS: S ? 9 actcitsA seal:01►•e 43 cep
(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 =$ 5C) 18O
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675