1984, 05-14 Permit App: 00000155 Residence*
BUILDING PERMIT APPLICATION WORKSHEET
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 (first) (m) Department lbe ly
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2 Project Address (no Mailing Address) a Road Nam e� Space Zip
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3 City/Community
State
Subdivision/Plat Name
4 Aseeeeor Parcel No
Q95-17.--e75—
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0
Zone
961/46(21
Project No.
155
6 Dwell#
No. of Buildings
Sq. Ft./Acre
Depth`
Frontage
v
7 Set Back -Front
3
(L S-1
181
(R)S 2
61t
Rear
Census Tract
Module No.Ipdial��
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16 Architect Firm Name
/ A/
/ 1G/'� f�
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
Contractor Firm N'C
/ �/V C -
Street d -C` � ` /J 7 -
Zip
992/
Gty
x°
State
Phone
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pnse N -¥/ 7 !
conte Per /41 �A` ,,rXBusiness
Phon(if differe)t than above
8 Owner`//Agent (if different than 01 above)
Address
9 Zip
City
State
Phone
( )
12 Review Required
PlanCheck (Y/N)
Other (Y/N) ISEPA Exempt (Y/N)
New
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
=i Ov C-
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
m- F -_-= 9 1 Z, 9. F. 4 X76
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Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
Conditions/Comments•
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit Issuance.)
❑commercial; E4rtesidential
New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION # 79 fid/
Release
Release w/cond 1
Hold 2
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments.
❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
O Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial;
O drainage
O road improvements
r7
sidential;
LV new access/approach;
O Flood Plain;
O fence;
„s&
6/7fri
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Tl 0
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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Spokane County
DEPARTMENT OF BUILDING &SAFETY
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
PARCEL NUMBER:
INFORMATION WORKSHEET
STREET ADDRESS: C A0V.22 .22 fair vie ti 4oe,
CITY/STATE/ZIP: %% DCI k_abt e Weic c 97206
SUBDIVISION: Fczf r" a, C /es
BLOCK: 36 LOT: ZONE: DISTRICT:
LOT AREA: F/A: WIDTH: DEPTH: R/W:
# OF BUILDINGS: #�OF DWELLINGS: WATER DISTRICT:
�/
OWNER:
J GL (/14 e 5 (/)'•CGe ,7 4 PHONE: - `2 ( - .3 7
MAILING ADDRESS: GC, e
CITY/STATE/ZIP:
CONTACT: PHONE: - -
SETBACKS: - FRONT: LEFT: RIGHT: REAR:
PERMIT USE:
***************************************************************************
BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
CONTRACTOR: PHONE:
MAILING ADDRESS:
ARCHITECT/ENGINEER: PHONE: -
MAILING ADDRESS:
NEW: REMODEL: ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: / STORIES: /e)
4E00 ENE.
BUILDING DIMENSIONS:
X ,3(WIDTH X DEPTH) SQ. FT.: J�
REQUIRED PARKING: # HANDICAP: SPRINKLERED: CRITICAL MATERIAL: