1993, 03-02 Permit App: 93001168 Sewer C6
SEWER/PLUMBING PERMIT-APPLICATION FORM (-- 3- \ ` o
INFORMATION WORKSHEET
aS-54
JOB STREET ADDRESS: i .� I 77(f I`'i , f f1,. .
CITY/STATE/ZIP: 14 ,. Sp,k-u-e.PARCEL NUMBER:
MAILING ADDRESS: -S.okt e
OWNER: L^) PHONE NUMBER: Ci-C,-S7Co
(Street) (City/state) (Zip)
CONTRACTOR: H E S CIoN572ucT IO)4 LICENSE NUMBER: HSCON',4c I23KF
PHONE NUMBER: q26-139404 T
MAILING ADDRESS: 11817 UALLEVIdd AVE SPok1rNE WA cichwo
(Street) (City/state) (Zip)
�{
X EACH
DESCRIPTION UNIT =AMOUNT VjI°1,
SEWER CONNECTION X 50.00= ��
PLUMBING ALTERATIONS X 35.00=
D-
\\CL
SUBTOTAL $
EQUALS: TOTAL U�Sa �e`�l`
PEMIT FEE DUE _$ S a r��'
SIGNATURE ` ?c___. 4 v
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Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675