1994, 02-16 Permit App: 94001193 SewerA5z)3 Z 7q -1lq3
�ZSEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET
F
JOB STREET ADDRESS: y /TUU /d 7-1. �S l47
CITY/STATE/ZIP:,5p"-'—` gq,70G PARGELNUMBER:
MAILING ADDRESS:
(St eeI) (city/state) (zip)
CONTRACTOR: �� IIr`p. /`2d V LICENSE NUMBER: rV < « 1,0ca 3 1100
PHONENUMBER: 4/7 Z 4,"-5'3 2
MAILING ADDRESS: 1-1c-I.f5-14 / y p rad, I
(Street) (City/state) (Zip)
DESCRIPTION
SEWER CONNECTION
PLUMBING ALTERATIONS
X EACH
UNIT =AMOUNT
X 50.00 =
X 35.00 =
SUBTOTAL $
EQUALS: TOTAL ,{
/,//,J�
PEMIT FEE DUE_ =$ (/
SIGNATURE /I r
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-365