1984, 04-20 Permit App: 84A-3632 Residence Addition 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))) Department Use Only
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2 Project Address(not Mailing Address or Road Name Space Zip
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3 City/Community State Subdivision/Plat Name
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4 Assessor Parcel No. Lot Block
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5 Sic Code/�j * * * DEPARTMENT USE ONLY * * *
Zons_C Act.N Zone Project No.
' 6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage
I 1
7 Set -Front I(L)S-1 (R)S-2 Rear Census Tract Module No. Initials
ii
* 16 Architect Firm Name Street Address *
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm/Name Street Address
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Zip (J City State Phone
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Contact Person License No. Phone If different than above
( )
8 Owner/Agent(if different than 01 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 f, Bldg ❑ MH E New ❑ Replace ❑ Other
❑ Fire ❑ Demo X Add/Alter ❑ Move
14 Describe Work
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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
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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 E Commercial; E Residential
W.1101 College E New Construction; E Bldg alteration/addition
Room 200 O Additional structure;
APPLICATION#
Conditions/Comments:
LI Planning/Zoning: 0 Commercial; O Cert. of Exemption; D Frontage;
N.721 Jefferson 0 Setbacks; lot w/d; 7 lot size; 0 use/zone; .
0 CU,variance,zone change;shoreline; E fence;
0 Other
Conditions/Comments:
Engineers: 0 Commercial; 7 Residential; E Flood Plain;
N.811 Jefferson 0 drainage El new access/approach; 0 fence;
0 road improvements
Conditions/Comments:
Utilities:
N.811 Jefferson
Conditions/Comments:
LI Other:
LI Plan Exam
Fire Prey.
Conditions/Comments:
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Project Representative Telephone
a)
Agencies Performing Special Inspection:
1.
2.
"i7) 0
3.
1 indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
STATEMENT
RALEIGH D. PETTY
GENERAL CONTRACTOR
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I``, SPOKANE8921NORTH, WASHINGTONLEHMANROAD 99207
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9) 924-0773
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