1992, 07-20 Permit App: 92005463 Sewer SEWER/PLUMBING PEPIM!T APPLICATION FORM
INFORMATION WORKSHEET
( 27``—
JOB STREET ADDRESS: E, 133
CITY/STATE/ZIP: PARCEL NUMBER:
Sp k e �--
MAILING ADDRESS: Z
OWNER:An, k � '� 1 k PHONE NUMBER: 2 ---7/i
(Street) (City/state) (Zip)
CONTRACTOR: (+-01"1- LICENSE NUMBER:A (3(-.R-s c 019 3-N
�,k.sfi i
PHONE NUMBER: g 2 -
C, ( �`) S ci-a v- (e, la- (r Ir�e�-c c ror �✓A QiG d
MAILING ADDRESS: (Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT
(SEWER CONNECTION X 50.00= 513
PLUMBING ALTERATIONS X 35.00 =
SUBTOTAL
EQUALS: TOTAL
PEMIT FEE DUE =$ 5-0
SIGNATUR —�
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675