1992, 12-11 Permit App: 92010861 Plumbing ReversalSEWER/PLUMBING PERMET APPLICATION FORM ._12_..1 cA(p
INFORMATION WORKSHEET
JOB STREET ADDRESS: /3 a2/,9
CITY/STATE/ZIP: PARCEL NUMBER:
MAILING ADDRESS:
OWNER: PHONE NUMBER:
(Zip)
(Street)
CONTRACTOR: / G = C/�
MAILING ADDRESS:
(City/state)
LICENSE NUMBER:
PHONE NUMBER:
%-
(Street)
(C/state)
(Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT
=AMOUNT
X 50.00 =
X 35.00 =
<. 1_2l')
SUBTOTAL
$
EQUALS: TOTAL
PEMIT FEE DUE
=$
��.
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675