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1992, 09-15 Permit App: 92007665 Sewer
SEWER/PLUMBING PERMIT APPLICATION FORM � �-, INFORMATION WORKSHEET c?-5' JOB STREET ADDRESS: E 3/2' q -1(1 CITY/STATE/ZIP: fr46' i W4 qqZ/(o PARCEL NUMBER: ► I , OWNER: 3 LiI J4 / o -) PHONE NUMBER: q 2-g - I SG MAILING ADDRESS: (Street) (City/state) (Zip) CONTRACTOR: 13O 3 Lew LICENSE NUMBER: LO&JG le RA 2 44 ieb PHONE NUMBER: MAILING ADDRESS: S • 9 4/S •070'5- fit, / ' 0,4u.eyPoiA, (,0/4 . 99034. (Street) (City/state) (Zip) XEACH \', C.F'. C O DESCRIPTION UNIT =AMOUNT NIOCL �qcc SEWER CONNECTION X 50.00= a�0 ' V-T(-� PLUMBING ALTERATIONS X 35.00 = �� C .0()9 `'C EQUALS: TOTAL SUBTOTAL $ 50c bAk PEMIT FEE DUE =$ l' k° SIGNATURE ACA-51N11 Spokane County Department of Buildings 1, West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675