1993, 03-19 Permit App: 93001633 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM �3 •
INFORMATION WORKSHEET �., �j
JOB STREET ADDRESS: )'33o`1 C • 3}L• 7 473
CITY/STATE/ZIP: Spale-�ei cATA . PARCEL NUMBER: ✓
MAILING ADDRESS: — S4
OWNER: Let)y,...5 PHONE NUMBER: -`{-S4 g cj
(Street) (City/state) (Zip)
CONTRACTOR: H i S aONSlieLlcitokl LICENSE NUMBER: HSCON iAg Ia3K+=
PHONE NUMBER: 926-89/04 A
MAILING ADDRESS: E 11811 VALLEVIJAY AYE 990k+rNe WA 99a0to
(Street) (City/state) (Zip)
XEACH 35 "f°5
DESCRIPTION UNIT =AMOUNT G
SEWER CONNECTION X 50.00= co
PLUMBING ALTERATIONS X 35.00= .7
12
SUBTOTAL $ ` ,'0u" G
EQUALS: TOTAL W a'?,
PEMIT FEE DUE =s Sv 45aa''
SIGNATURE �� 1
1
pokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675