1985, 07-19 Permit App: 00006520 Residence (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
I Project Number !_
Owner's Name LAST FIRST M I `F'
SMITH, Forrest R. and Achara M.
Project Address(Street Name&Number)
Zip
North 1115 Tshirley Court , Greenacres , WA 99016
Applicant Address
Jerry D. Stauffer North 4135 Garry Road
City State Zip Phone
Otis Orchards WA 99027 (509 ) 928-1248
Business Phone
(509 ) 928-1248
Contractor/Agent Address
Hildahi Construction North 4904 Campbell Road
City State Zip Phone
Otis Orchards WA 99027 (509 > 926-5005
Contact License Number(Required) Business Phone
Bruce Hildahl HILDAC233N4 (509 ) 926-5005
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( I
Lender Address
City Mortgage Services, Inc. East 12211 Broadway
City State Zip Phone
Spokane WA 99206 (50� 922-41)41
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DEPARTMENTAL REVIEW
Cond.
{/ l!�y Approved Approval Hold
Environmental HealthWPermit Number �5 QO p�i� ,z
Room 1 2 2 00 College 7/6-ii,__
(Z.,€/zte,:r/-- degee...M,M4,y,....4,7' c..,$),-, . ..e.r."-
Planning/Zoning
❑ N.721 Jefferson
,II
Engineers Permit Number _,,t1C,e}- ._ 7- /...--%
N.811 Jefferson illiPo-
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leUtilities • •� a 7"-2? I
l!� N.811 Jefferson (S T wv�."ek
7-
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Plan Review/Fire Prevention
❑ N.811 Jefferson /sr
Other(SEPA/Critical Material/etc.)
Ell
❑ 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 is tr ,correct, -g� .i
Owner's Signature ifleDate
Show on Site Plan:
Additional Information:
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 Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description Lot 6 , Block 1
of Zangar's Addition to
Greenacres commonly known
as North 1115 Tshirley Ct.