1986, 06-23 Permit App: 00011779 Pool(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 Pr --7
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Owner's Name LAST
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Project Address (Street Name & Number)
Zip
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Applicant
Address
City
State
Zip
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Phone
Business Phone
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Address� /
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State - - A
ZIP9,
Phone
Conta
Li se Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City State
Zip
Phone
( 1
Describe Work
Res. Comm.
Subdivision I Plat NamelSho;�A�a�tt,Number
y
Assessor Parcel Number
Lot
Block
Plat Number
y
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot (Sq. Ft./ Acre)
Depth
Frontage
Size
silo
Front Setback Left Setback r
Right Setback
Rear Setback r
R/ W Width i
Additional Information
Square Footage
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Z
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13
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Nur of Bedrooms.
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Building Technician Date
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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 Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
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
Chnw nn Ci#n Dien
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking St, -p-+
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Desc—�}——�--
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I hereby certi y_..�uesitionj
hat I-surve ed,the abolve described property Ind that'I fi#ld t e improvements to
L6 Ji! he premises In an that they 4o not CDCI.OSCh_,pII IOpert� I*ttg Ldjaeent there o— -�----
EX E T.-
Nb improvem,nts engroa h on these premises—Except:
OWNER
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Spokane,
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