1992, 09-14 Permit App: 92007538 Sewer SEWER/PLUMBING PERM)T APPLICATION FORM C r
INFORMATION WORKSHEET `j
/4:7 °`� 3JOB STREET ADDRESS: "' /3 9D--r)
:
CITY/STATE/ZIP: 5.p., //, PARCEL NUMBER:
MAILING AD ESS:
OWNER: PHONE NUMBER: of - Q 0
(Street) (City/state) (Zip)
CONTRACTOR: H it S cON5121.4C1 toKS LICENSE NUMBER: HSCO1 .41'012344.F.
PHONE NUMBER: 92/c'89104 F
MAILING ADDRESS: E 11817 VALLYkI Y AVE BP°k4 NE WA 99000
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT �GJ
SEWER CONNECTION X 50.00 =
PLUMBING ALTERATIONS X 35.00= ti3 i -i,?
SUBTOTAL $
EQUALS: TOTAL P LaaL\*7 `1°\'
PEMIT FEE DUE _$ 1310 \‘7P
SIGNATURE
Spokane County Department of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675