1992, 09-23 Permit App: 92008004 Sewer r
SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS: l 3 3 Z O E /J1
CITY/STATE/ZIP:�Q 9 Z- / C PARCEL NUMBER: ?5- 2-2- I, , Z 0 Z
OWNER: e-te--+'Ljv PHONE NUMBER: cl 2- ' S '
MAILING ADDRESS: /3 320 £L. '7 /1-0 5c v 6`-) • c zC Le
\T
(Street) (City/state) (Zip)
CONTRACTOR: \ I t C s'---- LICENSE NUMBER:
PHONE NUMBER: ATG a^ O 4 9L
MAILING ADDRESS:
(Street) (City/state) (Zip)
X EACH l 9
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00 = Q��
PLUMBING ALTERATIONS X 35.00 = p
ULI
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE =$
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675