1992, 06-18 Permit App: 92004490 Sewer CA2_ y4gO
SEWER/PLUMBING PERMIT APPLICATION FORM ao Sy
/ am"
INFORMATION WORKSHEET
JOB STREET ADDRESS: A^ J9 S- /y V eZ5 G2.5" (03`B
CITY/STATE/ZIP: 5 PARCEL NUMBER:
OWNER 42'h %
/ a%'. PHONE NUMBER: 9026' a4/
MAILING ADDRESS:
(Street) (City/state) (Zip)
CONTRACTOR: H SCONSTaUCTIoN LICENSE NUMBER: 145 CON*4,12.3KF
PHONE NUMBER: g2(o-891v�{
MAILING ADDRESS: • 1181'1 UAu.E1WAi AYE SPOLANE WA G(31aOlo
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT MOUNT
SEWER CONNECTION X 50.00=
PLUMBING ALTERATIONS X 35.00 =
SUBTOTAL $
EQUALS: TOTAL
PEMIT FEE DUE =$ q-S�
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260(509)456-3675