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1992, 07-02 Permit App: 92004940 Sewer SEWER/PLUMBING PERMIT APPLICATION FORM V INFORMATION WORKSHEET V' \.__, JOB STREET ADDRESS: / 4=2 A,1- �� CITY/STATE/ZIP: /,' do • lam. - PARCEL NUMBER: ��� OWNER: �G Ce--2- > PHONE NUMBER: 9c c�— / ----0 MAILING ADDRESS: - .e'-�'x__Q ..:--__, (Street) (City/state) (Zip) CONTRACTOR:COUP-CFlsoki€ EXCAVA7►ot4 LICENSE NUMBER: COU CCC )`1161 gel PHONE NUMBER: al x4-5,485 `1 V'MAILING ADDRESS: E. Ilot-I6a VAc.t_EyW Ay AVE VEeAf ALE ln1A R9037 (Street) (City/state) (Zip) C_ i X EACH -tel I' DESCRIPTION UNIT =AMOUNT CP-r- n SEWER CONNECTION X 50.00 = ,3"----0 �.) `� PLUMBING ALTERATIONS X 35.00 = \J SUBTOTAL $ D G EQUALS: TOTAL � �7 �A� PEMIT FEE DUE _$ 6-9&.6 SIGNATURE .e . Lac.- e_1 �c r2 ') �t Spokane County Department of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675