1985, 03-04 Permit App: 00004010 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
F1 Fiss.
I
Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
3yta `'w.\ ,.,.r `- T9'e
3 City/Com unity
State
Subdivision/ Plat Name
4 Assessor Parcel No.
'-5
j 4, — 24 c 2_
Lot
Z
Block
,t ,t * DEPARTMENT USE ONLY ,t * ,t
5 Sic Code
Zone Act. M
Zone .r
Project No.
6 Dwell 8
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Bads -Front
S`
(L)S-1
. 2
(R)S-2
IF_
Rear
ece)
Census Tract
Module No.
Initials
rig,,/
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
'01 lAatA1 (':k
Street
l'%,
Address
Lae-ct:,y LA -,...((L el,
Zip
Clty
State
Phone
Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than 4.1 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
SEPA Exempt
(Y/N)
Date
15 Type Work d Bldg
❑ Fire
❑ MH
❑ Demo
Eri ew
0 Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
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 �' y j f
Ai /Ei E(__, �I (...
\.
ie rr 1 ! '
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:
D Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1
Hold 2
NM
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;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments•
O Commercial;
❑ drainage
❑ road improvements
0 Residential;
0 new access/approach;
/L--fi --emg
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
Plan Exam
Fire Prev.
Conditions/Comments
/7;2341�
Project Representative
Agencies Performing Special Inspection:
1
Telephone
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) 667.6481
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