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1992, 12-02 Permit App: 92010531 Sewer
SEWER/PLUMBING PERMIT APPLICATION FORMO 2 5, 9c1 INFORMATION WORKSHEET Oj'i \-\ JOB STREET ADDRESS: - • /0 /y / O 53 t CITY/STATE/ZIP: 2 G PARCEL NUMBER: MAILING ADDRES5 �2 �v j �1 PHONE NUMBER: OWNER: --5 (Street) (City/state) (Zip) ONTRACTOR: . W S AGTIV E LICENSE NUMBER: A LWA A (5�P5 C PHONE NUMBER: 9aa- O ,. 1y l5l�a �PekAnt WA '9a1 MAILING ADDRESS: . a .----6.. (Zip) (Street) (City/state) =AMOUNT DO Vbk � DESCRIPTIONBM � n D SEWER CONNECTION X 50.00 = V 1 {{�� PLUMBING ALTERATIONS X 35.00= PCv" SUBTOTAL t)e 1111111111111 EQUALS: TOTAL ©� G`�� 1 p -1e41T FEE DUE SIGNATOR Spokane okane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675