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1992, 07-07 Permit App: 92005025 Plumbing Reversal SEWER/PLUMBING PERMIT APPLICATION FORM INFORMATION WORKSHEET �� M ,, JOB STREET ADDRESS: /3//.Z A-' ' Gr "<: ,11 GO 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 n 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