1985, 04-30 Permit App: 00005281 MH BUILDING 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)) i I Department Use Only
/ -47zirbR 4/a11 „1:2 !,_ �. Comm
2 Project Address(not Mailing Address)ar Road Name Space Zip
• 180O7 PO / tieAj
( 3 CI /Community State Subdivision/Plat Name
•
r�c�l7l�li'� i¢
4 Assessor Parcel No. Lot Block
c y1�/— . '/�� * * * DEPARTMENT USE ONLY * * ,t
5 Sic Code Zone Act.k Zone Project No.
ACC"(211 '
I
6 Dwell# No.of Buildings Sq.Ft./Acre Depth i L Frontage
t I. 8 / ,2_c i r-7 0
7 Set Back-Front* (L)S-1 (R)S-2�t I Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street Address
Zip City I State Phone
( )
Contact 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 p_Bldg XI MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work
1.4 X (40 PetilinE-
.K
p licant NamStreet Address
Qin tiS /7� r �G�1®� /A /' /
11 Zip
�� City_ State Phone
09) _ 'T-74a,
Lender Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Additional Information
DEPARTMENT APPROVALS
This is nota Permit
Application Type
(Standard unless (Indicated approvals required in either"release"or"release with conditions"
otherwise indicated) space prior to permit issuance.)
❑ Fast Track
❑ Early Start Release
`� Release w/cond 1 Hold 2
" Environmental Health ❑ Commercial; ❑ Residential /A ,S
W.1101 College J81 New Construction; ❑ Bldg alteration/addition liy` 61
Qoo� ❑ Additional structure;
APPLIC TION#r :5-633?
Conditions/Comments: 401467
p2_1 ' /
_________
194,Planning/Zoning: ❑ Commercial; [41-‘.of Exemption; ❑ Frontage; /4Ig
t
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
0 CU,variance,zone change;shoreline;
0 fence;
❑ Ot
�� __...-
g- -.—
Conditions/Comments:
•a�p �! C' ' I_ , • eZ.-/O --0 5.
�� r , / ./I
Ni Engineers: 0 Commercial; 0 Residential; C3'Flood Plain; 4 J/
N.811 Jefferson ❑ drainage i81 new access/approach; ❑ fence; y /
0 road improvements
Conditions/Comments:
,ir = -
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
❑ Other:
t
El Plan Exam
Fire Prey.
Conditions/Comments:
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`0 Project Representative Telephone
U
a Agencies Performing Special Inspection:
co
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H- E 2.
N O
as C
LL
3.
1 Indicate above or attach conditions relative to final as built approval
2 indkate above or attach reasons for hold
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Dept
VBNDOR
i Ls, TTS WII.I.IAM
8007 E RIVER R7
3RE NACRES
Vendor CorttacUTel
LGFS PAYMENT DOCUMENT
SPOKANE COUNTY AUDITOR
SHIP TO: BILL TO:
Confirming Order
Change Order #
Bid ID
Blanket#
RC#
VI#
FOB:
ACCTG. PERIOD:
COMMENTS -
COMM LN#
DESCRIPTION
PO DATE: BLDG/ROOM:
DELIVERY DATE: WAREHOUSE:
ENTERED BY -
BUYER
PURCHASING DIRECTOR'
COMMODITY NO
REF ACCT LINE
QUANTITY
UNIT
UNIT PRICE
TOTAL PRICE
18007 E RIVERWAY
PAGt TOTAL:
DISCOUNT TOTAL:
FREIGHT TOTAL:
SALES TAX TOTAL:
PURCHASE ORDER VALUE:
VS'm TAX TrTAL:
366.14
0.00:
0.00
0.00
366.14
.')
GINE NO.
FUND
AGCY
ORG
SB ORG I ACT
OBI
SB OBI
REV SRC
SB REV
RPT CAT
BS ACCT
JOB NO.
PAY THIS AMOUNT
P/F
RECEIVING CERTIFICATION
Materials noted in quantity J have been
received in good condition or contracted for.
SIGNED
TITLE
DATE
OA 4
12/2'c:
PAYMENT CERTIFICATION
1, the undersigned do hereby certify under penalty of perjury that sufficient funds have been budgeted for this claim, the
materials have been furnished, services rendered or labor performed as described herein or contracted for, that the claim is
a just, due and unpaid obligation against Spokane County or fund agency indicated above, that 1 am authorized to authenticate
and certify to said claim.
SIGNED
DATE
.Ira OWFIC:E .ADMINISTRATOR
DEPARTMENT 2
TRAVEL CERTIFICATION
1 hereby certify under penalty of perjury that this
is a true and correct claim for necessary expenses
incurred by me and that no payment has been received
by me on account thereof.
SIGNED TITLE
DATE PAGE