1993, 03-01 Permit App: 93001124 SewerSEWER/PLUMBING PERMIT APPLICATION FORM kcal
t5 INFORMATION WORKSHEET
JOB STREET ADDRESS: : I 05 -
� a
CITY
/STATE/ZIP: 401cc1-,.0, (k,1f3 PARCEL NUMBER: ¥,S.-40 r , 1
MAILING ADDRESS: - (14kE - {3
OWNER: - (--I V_ 1, I r\A ,,� r PHONE NUMBER: 1i -2- 3 (O K p�
(Street) (City/state) (Zip)
CONTRACTOR: H i S CtoNSieUC.Tro1.1 LICENSE NUMBER: HSCON ,' 13.31(F
PHONE NUMBER: 926 -8944
MAILING ADDRESS: E 11817 UALLEY42,01 AVE SPok+cnNE WA 94aa10
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X 50.00 =
X35.00=
3< -
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
_$
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675