1985, 02-13 Permit App: 00004012 ResidenceBUILDING 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)
Department Use Only
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2 Project Address (not Mailing Address) ar Road Name Space Zip `/�
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_-
3 City/Community
r
State
Subdivision/Plat Name
`
4 Assessor Parcel No.
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Lot
Block
j
`
* * * DEPARTMENT USE ONLY * ,t ,t
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell ff
/
No. of Buildings
/
Sq. Ft./Acre
Depth
i 'Z S
Frontage
8
7 Set Bade -Front
(L 8-1
(R)S-2
Rear
Census Tract
Module No.
Initials
4 16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
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Street
1,
Address
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Zip
CI qtr. --
City
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State
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Phone
( ) ct 2 (.,. —os
Osntact Person
License No.
Phone If different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (Y/N)
I SEPA Exempt
(Y/N)
Date
15 Type Work
❑
Idg
Fire
❑ MH
❑ Demo
B" ---New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
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cup -/4'/4r-,
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
pip- ---
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E
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions/Comments•
❑ Commercial;
❑ New Construction;
O Additional structure;
APPLICATION #
❑ Residential
❑ Bldg alteration/addition
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Release
Release w/cond 1
Hold 2
M`A
El
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments.
O Commercial; 0 Cert. of Exemption; ❑ Frontage;
❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
O drainage
❑ road improvements
O Residential;
O new access/approach;
❑ Flood Plain;
❑ fence;
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Utilities:
N. 811 Jefferson
Conditions/Comments.
Information
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
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
•
Coeur d'Alene Trusses. Inc.
655 WEST CLAYTON AVENUE • COEUR D'ALENE, IDAHO 83814 • (208) 867-6481
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