1992, 10-07 Permit App: 92008547 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET C P 3 , /1) $`
JOB STREET ADDRESS: G. 13 Zo2 - �{-1,,. q 5L
CITY/STATE/ZIP: kanc� t,cSA• PARCEL NUMBER:
MAILING ADDRESS: 5A ME
OWNER: (-rc,.ry Jo1�rs4-c.r\ PHONE NUMBER: q2 -yyRL
J (Street) (City/state) (Zip)
CONTRACTOR: H F S Cons{-rucl•ian LICENSE NUMBER: HSCaiJ It 'l- Z,31C P
PHONE NUMBER: `'t 2,(D-8ricaL{
MAILING ADDRESS: E.• 11211 UAuE11-d y AuE. SPeKAkte., W A. 997-0(0
(Street) (City/state) (Zip)
X EACH L00
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00= ) SO
PLUMBING ALTERATIONS X 35.00 =
SUBTOTAL $ So
EQUALS: TOTAL
PEMIT FEE DUE =$ So
SIGNATURE (�7t
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675