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1992, 10-27 Permit App: 92009416 Sewer
SEWER/PLUMBING PERMIT APPLICATION FORM 0 9i /INFORMATION WORKSHEET ES ' /. /9 / .--- i�6 Ct °�aS - 1, JOB STREET ADDRESS:S: ' CITY/STATE/ZIP:�� — - - � a' PARCEL NUMBER: p \P 4--)---e----19e12---t$4/ ,�-��',,� / PHONE NUMBER: p- -p/'7�-� �a OWNER: N � G(..� MAILING ADDRESS: 1 (Street) (City/state) (Zip) CONTRACTOR: COUKCNAtme EiCAYhTiol'( LICENSE NUMBER: COLt.E.CC-7#18S-C7 PHONE NUMBER: ga4"5y85 MAILING ADDRESS: G. llotgO2. VALLeit4A4 AVG vE2aDWA- clq 37 (Street) (City/state) X EACH • Ve2I1 DESCRIPTION UNIT =AMOUNT Ga3�, , \ ' (SEWER CONNECTION X 50.00= " Ote7 �� PLUMBING ALTERATIONS X 35.00 = ° ���� ��� SUBTOTAL $ �` �� EQUALS: TOTAL .��/ d`o PEMIT FEE DUE =$ O S SIGNATURE it 0 - e--4-e--(- 44 -- Spokane County Department of Buildings West 1303 Broadway Avenue Spokane,WA 99260(509)456-3675