1992, 07-07 Permit App: 92005025 Plumbing Reversal SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET �� M ,,
JOB STREET ADDRESS: /3//.Z A-' ' Gr "<: ,11
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CITY/STATE/ZIP: .5'�0 4 /{a,in- (-- PARCEL NUMBER: �aa . Zf l
MAILING ADDRESS: 6
OWNER:A1 eh,aa LAe-ili PHONE NUMBER: 9‘.2..S) - ?J i"e
„I--I A ((.� t / (City/state) (Zip)
CONTRACTOR:I I-geLICENSE NUMBER: 'D''?:�3 .P4,-46
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PHONE NUMBER: /
MAILING ADDRESS: / // L:_ 47 c' er/�c�.ri-P ?q.2_/‘(Street) (City/sf e) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00=
PLUMBING ALTERATIONS X 35.00 = I r
SUBTOTAL $
EQUALS: TOTAL OD
PEMIT FEE DUE =$
SIGNATURE_ � -- {._
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675