1985, 04-05 Permit App: 00004801 WorkshopBUILDING 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 / (last) (first) (m)
kt 1/ fr 5-� (9 EAA lit)
Department UsepnIy
FIs. Comm
/{,
2 Project Address (not Mailing Address) or Road Name Space Zip
s. 7/ 6/
3 City/Communi y
State
WI ^—
Subdivision/ Subdivision/Plat Name
c PP 61 c rc e-,„ 4 b6/s
4 Assessor Parcel No.
9/ ' u _ 1 3 y D
Lot
5
Block
3
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. M
Zone
As
Project No. to
6 Dwell
1
No. of Buildings
I
Sq. Ft./Acre
Depth 1
1QAD
Frontage
(,Q.77
7 Set Bads -Front
P— c,47 -n r i Co
(L S-1 1
, s
(R)S-2
Rear
-
Census Tract
Module No.
Initials
J 0 YY1 .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Per30n
Phone if different than above
( )
Contractor Firm Name i41,1N/ /nStreet
c.,..\ k„ 1�1 C� Cryt` ,
Addressj1
�`1,2 / �• Le(.cl.�rc ,,
Zip
c 7
City
5126:
State
1 Lac
Phone
( ) 9�2 �/ - 07 7 3
(9
ContactPeerrson
License No.
P-M,V-1 G& 2z [ pU
Phone if different than above
( )
8 Owner/Agent (if different than 91 above) ''./.3//45(0
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) 1 SEPA Exempt (Y/N)
Date
,i 15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work 1 t
0(z ki-o r p_ 7- Z
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
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
This is not a Permit
•
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
RI
Environmental Health ❑ Commercial; ❑ Residential
vv. 10College om 200 ❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;Q
/�
-s-7
APPLICATION # Q /4urD
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; ❑ use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new access/approach; 0 fence;
0 road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative Telephone
IInformation
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
STATEMENT
RALEIGH D. PETTY
GENERAL CONTRACTOR
8921 NORTH LEHMAN ROAD
SPOKANE, WASHINGTON 99207
(509) 924-0773
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