1992, 09-16 Permit App: 92007677 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
1�JOBSTREET ADDRESS:
/f 1 l/
CITY/STATE/ZIP: ,V( PARCEL NUMBER:
f'
MAILING AD,+ 'ESS: --
OWNER: ii PHONE NUMBER: _
(Street) (City/state) (Zip)
CONTRACTOR: HES CON572UCT roKI LICENSE NUMBER: HSCON t 3KF
PHONE NUMBER: 926-MIA k
MAILING ADDRESS: 118)7 IlAilEk11410 AYE BPoke NE WA 1a0(o
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00=
SUBTOTAL $
EQUALS: TOTAL y�
PEMIT FEE DUE _$
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675