1985, 02-06 Permit App: 00004101 ResidenceBUILDING PERMIT APPLICATION WORKSHEET -'
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PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name ,Q (last) (first) (m)
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C Cr L3 L -%' ' t' _.S /-K'C
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Department Only
Fbs. Comm
2 Project Address (r16t Mailing Address) or Road Name Space Zip
0 A
3 City/Community
5'
State
Lug
Subdivision/ Plat Name
I
4 Assessor Parcel No.
G ff -5-41 Z/ ^ Q
Lot
Block
DEPARTMENT USE ONLY
5 Sic Code
Zone Act. #
Zone
CSi.c�
Project No.
6 Dwell #
i No. of Buildings
Sq. FtJ Acre
Depth
Frontage
7 Set Back -Front (QS -1 (R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
city
State
Phone
Contact Person
Phone If different than above
Contractor Firm Name
Street Address
Akyi %
ZipGty
State
phone
Contact Person
�.
License No.
2 . ' -v I , e-40�42' 21
Phone If different'than above
( )
8 Owner/Agent (if different thah #1 above)
Business Address
9 Zip
City
State
Phone
12 'Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (YIN)
Date
15 Type Work Bidg '
❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
resIc%Af6e,
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
AdditionalInformation
`tom
N1
1�� �.
DEPARTMENT APPROVALS'
1 Indicate above or attach conditions relative to final as built approval
2 . Indicate above or attach reasons for. hold
1 nis is not a vermit
Application Type
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Release w/cond 1 Hold 2
Environmental Health
❑ Commercial; ❑ Residential yC
W. 1101 College
❑ New Construction; ❑ Bldg alteration/addition
Room 200
❑ Additional structure; -
APPLICATION #
Conditions/ Comments:
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson,
❑. Setbacks; ❑ lot w/d; ❑ lot size; - ❑ use/zone;
❑ CLI, variance, zone change; shoreline; ❑ fence;
❑;,, Other . .
Conditions/ Comments:
❑
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;Gf I I
N. 811 Jefferson
❑, drainage ❑ new access/ approach; -❑ fence;
Conditions/ Comments:
❑ road improvements
— �-7�.
❑
. _ utilities:
; 7-T I
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
Plan Exam
Fire Prev.
Conditions/ Comments:
v
❑
.. -
Project Representative
Telephone
Agencies Performing Special Inspection: `
c
1.
O
E
0
2
3.
1 Indicate above or attach conditions relative to final as built approval
2 . Indicate above or attach reasons for. hold
�RCD S'B Y
CROSBY TERPRISES
FULL REAL ESTATE SERVICE
Realty QUALITY CONSTRUCTION - LAND DEVELOPMENT
TEL. 9222200 - N'. 1506 PINES ROAD - SPOKANE, WA: 99206
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A," OSBY
FULL REAL ESTATE SERVICE
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Realty: QUALITY CONSTRUCTION r LAND DEVELOPMENT
T h 7,'jl • SPOKANE, WA. 99206
..,,. TEL. 922-2200 • N. 1506 PINES ROAD
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