1992, 10-27 Permit App: 92009386 SewerSEWER/PLUMBING PERMIT APPLICATION FORM S, `to�
INFORMATION WORKSHEET ��
JOB STREET ADDRESS: - -a G. )! ? 3 Th 9, a. `35 c
CITY/STATE/ZIP: ,-kms L4Pfl PARCEL NUMBER:
MAILING ADDRESS: `..01,-(c--
OWNER:
f0►-(cOWNER: I'.)ct(_.� Q F<r,r)L.,,,rr PHONE NUMBER:
(Street) (City/state) (Zip)
CONTRACTOR: N f S Cc-rSi-nici-or- LICENSE NUMBER: HSCatJ 14- 1-2-74C F
PHONE NUMBER: ct 2-(0- gTcnU
MAILING ADDRESS: a. l la(1 Upu_kywQ.f P. SPdKAAle., 1.kiP4. 2-d(42r
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
SIGNATURE
X EACH
UNIT
=AMOUNT
X50.00=
X 35.00 =
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
_$
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675
L-4 I