1992, 09-14 Permit App: 92007539 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM `- '27
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INFORMATION WORKSHEET °O
JOB STREET ADDRESS:2 1. � O `7
CITY/STATE/ZIP: 97f, PARCEL NUMBER:
OWNER: D‘ .1-//Z e./00", PHONE NUMBER: r,? F` 1-' ;.7'
MAILING ADDRESS:
(Street) (City/state) (Zip)
CONTRACTOR: H S C,oNSTgUCTION LICENSE NUMBER: HS('Ont4E*12.3KF
PHONE NUMBER: q2(0-8q014
MAILING ADDRESS: C,. iI80 UAU.EyLAi AVE SPOkJNE WA gcta0(0
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT (iL
SEWER CONNECTION X 50.00= off` 9
PLUMBING ALTERATIONS X 35.00= J3 ,
SUBTOTAL $ a.'-4'�, t`'`'°EQUALS: TOTAL 6 i LAO
PEMIT FEE DUE _$ eicr Q:F.
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675