1993, 01-13 Permit App: 93000176 Plumbing Alteration i
SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS: LT(,c l.kt"LRr
CITY/STATE/ZIP: ' cc- , t PARCEL NUMBER:
MAILING ADDRESS: A-C —
OWNER: RIc( r SL1N PHONE NUMBER: U 2G,- I c, (
(Street) (City/state) (Zip)
CONTRACTOR: [It-S CrnwI-n_cch - LICENSE NUMBER: IA-S- (u_) I23 F
PHONE NUMBER: i2(0
MAILING ADDRESS: F HAI? U41la � I-1.09 5L°
(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 =$ :)`:
SIGNATURE _ ,
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675