1993, 04-05 Permit App: 93002139 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM �
INFORMATION WORKSHEET �Cj `1
T34.
JOB STREET ADDRESS:. /7VA° I _—s
CITY/STATE/ZIP: C /�2 I J`� PARCEL NUMBER:
MAILING ADDRESS: -5
OWNER: PHONE NUMBER:
(Str6= (City
/state)/state) (Zip
CONTRACT- -: ' LJts`I S ACTIVE LICENSE NUMBER: A I-WAY A't`Sn(QPS
PHONE NUMBER: Q 1 .. 6^
. , ly 1s�a �PokANE WA -9a1
MAILING ADDRESS:
(Street) (City/state) (Zip)
X EACH
=AMOUNTC;Ige.(iYi / ,
DESCRIPTION UNIT C'
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00 = $
SUBTO •
EQUA : 'OTAL ca
'
00
`. PEM : F E DUE =$
ii N
SIGNATURE "iAlielrAii. . r
IsS• •kane County Department of Buildings
West 130 Broadway Avenue Spokane, WA 99260 (509)456-3675