1992, 08-04 Permit App: 92006021 Sewer 2og4 c25 - 115c
SEWER/PLUMBING PERMIT APPLICATION FORM q2, coazt
INFORMATION WORKSHEET I0 t,
JOB STREET ADDRESS:
%4111.►.AliwilA � ,.. E. 10(o ' l n(�Z I VE-eS I Y
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CITY/STATE/ZIP: �� c, ���PARCEL NUMBER:
MAILING ADARESS: _ f • ;- •
OWNER: • / PHONE NUMBER: </ ` _ ,,
// (Street) (City/state) (Zip) '-
CONTRACTOR: / 5 S LICENSE NUMBER: -
PHONE NUMBER:
MAILING ADDRESS:
(Street) (City/state) (Zip) e)
X EACH
DESCRIPTION UNIT =AMOUNT b (1(P
SEWER CONNECTION X 50.00= L52o Li •
PLUMBING ALTERATIONS X 35.00 =
SUBTOTAL $
EQUALS: TOTAL
/ PEMIT FEE DUE =$ S\'°
SIGNATURE A - 4/1/
U Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675
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