1993, 12-23 Permit App: 93012152 Sewer q3-)21sz,
SEWER/PLUMBING PERMIT APPLICATION FORM [ 935 -/ ! tg
INFORMATION WORKSHEET J
JOB STREET ADDRESS: E /11/0 7 * 93 -12-153
CITY/STATE/ZIP: PARCEL NUMBER:
MAILING ADDRESS:
OWNER: A-t.4 r PHONE NUMBER:
(Street) (City/state) (Zip)
CONTRACTOR: Pi LtAyol 5 ACTe V E LICENSE NUMBER: A LWAY A+ft-10(0f25
PHONE NUMBER: 9a0-8.5o0
MAILING ADDRESS: . O.( ly 15(o S' POkANE WA cT9aiq {'
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00 = ✓
SUBTOTAL $
EQUALS: TOTAL , v
PE FEE DUE =$Olitierfa
c
SIGNATURE `"_.
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675