1992, 10-27 Permit App: 92009387 Sewer '1
SEWER/PLUMBING PERMIT APPLICATION FORM l 1��,
INFORMATION WORKSHEET cc._ S -
JOB STREET ADDRESS: E i 3 3/ 3 7/-1, .0,-
CITY/STATE/ZIP: SF�L� Q urn PARCEL NUMBER: a 5c\ l7
MAILING ADDRESS: -. CA. ---
OWNER: I,,,, 1-(t j PHONE NUMBER: <2- NE3C)
(Street) (City/state) (Zip)
CONTRACTOR: H S C_ ns{-ruc -icin LICENSE NUMBER: HSCc,JJ $ 3 17:14<F
PHONE NUMBER: ct Z(a- Iseuzly
MAILING ADDRESS: E.• t I$l1 UA ywa.f Aue. SPeKAoe., uJ P. 9g2.o4,
(Street) (City/state) (Zip)
X EACH On -1
DESCRIPTION UNIT =AMOUNT jai �S� IO�a
SEWER CONNECTION X 50.00= ( C
PLUMBING ALTERATIONS X 35.00 = 1
SUBTOTAL $ ffi.PA \°`) n AEQUALS: TOTAL N1�PEMIT FEE DUE _$(C-i1C LA C--°
SIGNATURE I `
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675