1992, 06-18 Permit App: 92004489 Sewer aoSy
SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION�WORKSHE T
JOB STREET ADDRESS: /3 b/ - G Scx)TK BLP,k-E
CITY/STATE/ZIP:c�oi/[£ I G PARCEL NUMBER: /
OWNER. , p!'b'G� PHONE NUMBER: 9c 6 -• 3-747
MAILING ADDRESS:
(Street) (City/state) (Zip)
CONTRACTOR: H S CONS TAUCTlON LICENSE NUMBER: HSCON-I I'I23KF
PHONE NUMBER: Ci2(o-89 tog
MAILING ADDRESS: G.. 1181'1 UAU.EiWAi AVE SPOk,ANE WA cicwO(o
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT `AMOUNT q a.a i , t1o1
SEWER CONNECTION X 50.00 = Mooegs sure A.sr
PLUMBING ALTERATIONS X 35.00=
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE =$ s'd
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675