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1992, 11-10 Permit App: 92009967 Sewer
f SEWER/PLUMBING PERMIT APPLICATION FORM INFORMATION WORKSHEET (%i , , .1- (Q l� D- JOB STREET ADDRESS: z)--- - /('-) 976 - / f 6 1-/ ` c� CITY/STATE/ZIP:�-)� - � PARCEL NUMBER: _ . a3— _ OWNER: "1.--" lc_ ;__- _.� PHONE NUMBER: 62:::`' — �('- "- MAILING ADDRESS: (Street) (City/state) (Zip) CONTRACTOR: Q.A.2.0.14A1NE EXAVAfION LICENSE NUMBER: C.AUIZCC*1818--1 PHONE NUMBER: qaq —5y85 MAILING ADDRESS: E- t04001 VALLE`IWF 1 PcVE VEe .b LE WA 99037 (Street) (City/state) (Zip) X EACH �J\O3 DESCRIPTION UNIT =AMOUNT 0 SEWER CONNECTION X 50.00 = o.�5 0 -`v=w' PLUMBING ALTERATIONS X 35.00 = r 4"<-' SUBTOTAL $ Y t s' EQUALS: TOTALS _ , PEMIT FEE DUE =$�T� SIGNATURE t Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675