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1992, 07-21 Permit App: 92005563 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM Cif ,"55b INFORMATION WORKSHEET .7 2(==� JOB STREET ADDRES : . t)-(-_)\:-.-\ `� 9 ZS�' CITY/STATE/ZIP: o (CC'(, PARCEL NUMBER: MAILING ADDRESS: - 13a Lt.)64,4 `1 Cpo�S(O OWNER:DerVrAiSc `t PHONE NUMBER: G S (Street) (City/state) (Zip) CONTRACTOR�'r c LICENSE NUMBER:Tt`i p1 S CI�3 in rU l� PHONE NUMBER: q n - ,'CI MAILING ADDRESS: E, 1,13A a(Street)ccr W`i 1 (�Pq /state) (Zip) X EACH DESCRIPTION UNIT / =AMOUNT SEWER CONNECTION X 50.00= L. PLUMBING ALTERATIONS X 35.00 = SUBTOTAL $ EQUALS: TOTAL PEMIT FEE DUE =$ SIGNATURE Ao..,(4/1/\ I I aA � / of Buildings S•okane County Department 9 West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675