1992, 12-07 Permit App: 92010692 Plumbing Reversal SEWER/PLUMBING PERMIT APPLICATION FORM C z -JO bq 2
INFORMATION WORKSHEET
JOB STREET ADDRESS: �- . ( .3 (1'
- I 21-
I-4
CITY/STATE/ZIP:`5CC)le AL t , w A 1`i ZiC- PARCEL NUMBER:
MAILING ADDRESS: S C�� ,t E
OWNER:WIr-.v2 At csvtcs -k.v.c. Lc PHONE NUMBER: 3L1-`i 24-t -C4--i t Z
(Street) (City/state) (Zip)
CONTRACTOR: S�= lk. L.buAv_ cit L,r-\ LICENSE NUMBER:
PHONE NUMBER:
MAILING ADDRESS:
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
SEWER CONNECTION X 50.00=
PLUMBING ALTERATIONS X 35.00 = -55-- C.1 h
SUBTOTAL $ 'i- (:)(1.
EQUALS: TOTAL
PEMIT FEE DUE =$ S 5 . C 0
SIGNATURE_ 1 J/ "
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675