1993, 03-12 Permit App: 93001447 Sewer q 3— /tArr
SEWER/PLUMBING PERMIT APPLICATION FORM
INFORMATION WORKSHEET i S-t
JOB STREET ADDRESS: I ?'-1 Z3 C —t i-1/'
CITY/STATE/ZIP: <c)4_,kc ,�,,e) PARCEL NUMBER:
MAILING ADDRESS: -- Sc --
OWNER: 13,1< <Th 1.s - PHONE NUMBER: 0,Zy-ci i I
(Street) (City/state) (Zip)
CONTRACTOR: H + S LICENSE NUMBER: I-/-.S cU(‘' I 3 KA
PHONE NUMBER: 2(-0-S'S `f
MAILING ADDRESS: I I Y -) c 1.)4tt.�--, k_ .---,Q,_k_ .---, 1,t/el `. 1,t/el CI`c'"
(Street) (City/state) (Zip)
X EACH
DESCRIPTION UNIT =AMOUNT j_i(tle(e -[
SEWER CONNECTION X 50.00 = g
PLUMBING ALTERATIONS X 35.00 = oZ�- 3 20('SUBTOTAL $ 15
EQUALS: TOTAL Glac(LS P1--E-
PEMIT FEE DUE =$ co 4
SIGNATURE 1,. ),� 7 `
Sdokane County Department of Buildings i�(5
West 1303 Broadway Avenue Spokane, WA 99260 (509)456-3675