1992, 12-16 Permit App: 92011009 SewerSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET%
JOB STREET ADDRESS: LY1 n, 4- IC214 G
CITVISTATEIZIP;�,in PARCEL NUMBER: -�
OWNER: V PHO/NE NUMBER:
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MAILING ADDRES : /6P11,,f�J?)�(CO"fNLf�
ptreet)
CONTRACTOR.?- C LICENSE N
I PHONE NU
MAILING
(Street)
(Zip)
vUNIT=AMOUNT 11 G\Lai
X50.00=
X35.00=
SUBTOTAL $'
EQUALS: TOTAL
PEMIT FEE DUE =$ �114'
SIGNATURE 'L' '
Spok ne County DePr[ment of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675