1986, 08-22 Permit App: 00012799 Residence Addition(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE -mv�-
Project M1lumc r
Owner's Name 1
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FIRST MI
Project Address (Street Name & Number)
Zip
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor/ Agent
Address
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CityState
Zip
Phone
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ContactLicense
Number (Required)
Business Phone
Architect l Eng i neerAddress
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City State
Zip Phone (
)
Describe Work
Res.Comm.
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Subdivision/ Plat Name/ Short Plat Number
Assessor Parcel Number
Lot 31ack
Plat Number
Pertinent File Numbers
Zone Comp. Plan
Census Tract
Number of Dwelling Units
1
Number of Buildings
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Lot Size (Sq. Ft.; Acre)
Depth
Frontage
Front Setback
Left Setback
Right 6etback
Rear Setback
JR/ W Width
Additional Information
square Footage
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Number of Bedrooms
Building Technician—Group
Date --T
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SPOKANE COUNTY HEALTH DISTRICT p _ /C,
ENVIRONMENTAL HEALTH DIVISION APPL•# D
9 '0 -3 / r) Z:)
FINAL INSPECTION FOR SEWAGE SYSTEM AT !at or section, township, and range and road)
(numerical address or lot and block in p
Please fill out in heavy
dark ight edge. Plan
line (felt-tip pen or equal) with a stra
e) as its
rs
n the
is to include outline of structureualflocationlof septic tanktldrainfieldolines,
prop-
erty. Identify by measurement act
drywell, or other on-site sewage facilities, property lines closest to drainfiel ,
on-site well (when applicable), driveway, and road frontage. Septic tank access
must be referenced to a known fixed surface structure.
NORTH
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FINAL INSPECTION MADE BY (I(DATE) NAME)
COMMENTS:
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■❑
■❑
A
01
0
0
DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature �-1�-�'/?�'��
Date <l
Approved
Cond.
Hold
QApproval
Environmental Health Application # p F n
W. 1101 College
Room 200 / jf
If
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature �-1�-�'/?�'��
Date <l