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