1985, 03-15 Permit App: 00004429 Residence C IA
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1
(Please return this original and your building plans to the Department of Building and Safety)
1 Orooner's Name // (last) (first) (m) D � Only
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2 Project Address(not Mailirig Address)or RoadJJame Space Zip
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3 City/Co/mmunity State Subdivision/Plat Name
4/Assessor Parcel No. Lot Block
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5 Sic Code Zone Act.# Zone Project No. i
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
1 � ) �Z
7 Set Back-Front (L)S-1 i (R)S-2 Rear Census Tract I 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
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Zip City
9f-1 4./ i;')�,/G I State Phone
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ContAt Person License No. Phone if different than above
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8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan C\'hfeck(Y/N) Other(Y/N) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH i1ew ❑ Replace C Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe Work ( /,
A c-1//t/ /'>e -C., dJoi../J--e- SI — &S; KZ)
10 Applicant Name Street Address
11 Zip City State Phone
( )
*
Lend/ ((er Street Address *
Zip City State Phone
Contact Person Phone if different than above
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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.)
R
F t Track
arly Start Release
Release w/cond 1 Hold 2
Environmental Health ❑ ommercial; Residential
W.1101 College V New Construction; Eli Bldg alteration/addition _,^
Room 200 El Additional structure; _ �...-
Oil 3 % �'
APPLICATION# tp� ` `I 0 y
Conditions/Comments: rL pe--k-iliii 771 fs -- -0-11-a-,r
El Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; ❑ Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
❑ CU,variance,zone change;shoreline; ❑ fence;
LI Other
Conditions/Comments:
ar
Engineers: ❑ Commercial; ,
❑ sidential; ❑ Flood Plain;
N.811 Jefferson 0 drainage new access/approach; ❑ fence; Op 0
'
❑ road improvements i k r-
Conditions/Comments: ..s -1s:,tro..2 7.41!ir�i f�� 7 ..f'_ : A»-9i._ 4����� _
El Utilities:
N.811 Jefferson
Conditions/Comments:
O Other:
E Plan Exam
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Fire Prey.
Conditions/Comments:
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UProject Representative Telephone
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Agencies Performing Special Inspection:
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1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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GENERAL CONTRACTOR
P. O. Box 14767 • Spokane, Wa. 99214
:,99/ 926-8520
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GENERAL CONTRACTOR
P. 0. Box 14767 • Spokane, Wa. 99214 926-8520
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