1992, 11-30 Permit App: 92010465 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
JOB STREET ADDRESS: E• 102 t S c+1,.•
aa- loU (05
CITY/STATE/ZIP: Spol;- (AA' PARCEL NUMBER:
MAILING ADDRESS: SAM1- S)
OWNER: AJC e;ear I PHONE NUMBER:
(Street) (City/state) (Zip)
CONTRACTOR: H S CansI-rucl-tcr, LICENSE NUMBER: l4SColJ
PHONE NUMBER: ct 2.10- y
MAILING ADDRESS: a• llgl1 VAtt.fctfLaJA� Al1E• SPoir e., uT 12 . 997_0(0
(Street) (City/state) (Zip)
X EACH �� ecaQ\Cd
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00= 50
PLUMBING ALTERATIONS X 35.00=
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE =$ . )
SIGNATURE
pokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675