1985, 01-03 Permit App: 00003838 Siding•
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)
(first) (m)
1 Owner's Name v�� (last) (first)
LL�z! r / /4eA tri 1
DepartmentUeeOnly
.5.
Comm
..C.(
2 Project Address (not Mailing Addless) or Road Name Space Zip
�• /o5?/ ,5f/ At). 99 io6
3 City/Community
.Spok�'YI. J
State
a)
Subdivision/ Plat Name
�i G� `i7 6 /
4 AssessorLot
1 Ci( (1
Block
it* * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
I Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
MU) PvG t_i erzy1er- Crn't AC vK, z --h(
Street Address
AI- X3/0( John �e)ccc�
Zip Gty
q � I kel��
State
A
Phone
($Oc)) 9.22— 416 8‘,
Contact Person
err j pc wag
License No.
/-k 'i -V8— C346' ' &
Phone If different than above
( ) �6
8 Owner/Agent (if different than S1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
I SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
0 Fire
❑ MH
0 Demo
El New
0 Add/Alter
0 Replace
0 Move
Otter
(`
14 ribe 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
( )
Additions/I�nforrmationn Y{' Q
l U
P Ancil- Fee --to
I
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
❑ Commercial;
O New Construction;
O Additional structure;
❑ Residential
O Bldg alteration/addition
Release
Release w/cond 1 Hold 2
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
O road improvements
Conditions/Comments.
❑ Flood Plain;
❑ fence;
CI
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Ci.
cs
C ❑
_O
U
N
a
c
Y O
U •
H E
o
c
LL
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
O road improvements
Conditions/Comments.
❑ Flood Plain;
❑ fence;
CI
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Ci.
cs
C ❑
_O
U
N
a
c
Y O
U •
H E
o
c
LL
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold