1986, 06-12 Permit App: 00011540 Addition/f
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
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(Please return this original and your building plans to the Department of Building and Safety)
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Project Number " S Gr U
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Owner's Name LAST FIRST MI
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Project Address (Street Name 8 Number)
S. /Y 05 477`11,74a./07 !L [X -1�/ Zip
APPlican, ,
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Address /���//7
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City
/State
Zip
Phone
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City%/tate
50A
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Phone
( I s.,..? 9'-°773
Contact 0
lttnse Number (Required)Business
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Phone
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Architect/Engineer
Address
City
State
Zip
Phone
( 1
Contact
Business Phone
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Lender
Address
City
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State
t
Zip
Phone
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'Plat Number
Pertinent File Numbers
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�Numberof Buildings.
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Lot Size (Sq. Ft./Acre) • '
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Depth " . ,.
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R/ W Width ..
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Number of Bedrooms
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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 Date
Approved
nd.
Approval
Approval
Hold
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EnvironmentalHealth Application N ,/Jlo /� 61--/-a
W. Iron01 Cental
Room 200 � .
.7.16,-i.-.._
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(�i/flOh 54 fC921oJ2,-- .�a s a —.4A
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 Date
5
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--r l —1 nTATEMENT
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RALEIGHP.-PETTY; !-
; GEN-EkLALI,-; 1 1 CaNTRAcToFt !
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13921_NQI9TH LEHMANIROAD
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"-SPOKANE WASHINGTON
(509)924-0773
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