1983, 03-23 Permit: 83A-2166 ResidencePLAN NUMBER - APPLICATION/PERMIT - ' PERMIT NUMBER
SPOKANE COUNTY - DEPARTMENT OF BUILDING & SAFETY
• NORTH 811 JEFFERSON / SPOKANE, WASHINGtON 99260 / (509) 456-3675
CHANGE OF USE FROM
TO
APPLICANT: COMPLETE NUMBERED SPACES — PRESS HARD TO MAKE 3 COPIES
1.
STREET ADDRESS
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--t? -: f
6.
PARCEL NO.
-39?+�
LOT I
BLrK
SUBDIVISION
9
LEGAL DESCRIPTION:
2.
c?
9 NEW ❑ ALT. ❑ AWN. 13 RPL. ElMVE.
I
021 W
�Z-
OWN R
PHONE
PHONE
3.
WORK Z BLD. ElPLMB. ❑ MECH. ❑ M.H. El POOL
Certifi.ofExempt.
Required
Yes❑ No❑
Number
MA ING ADDRESSf
or Variance
Received
Yea ❑ No ❑
2-07
Actual Set Backs in Feet to:
lWast I i
,
Shorelines/ Flood Hazard
Plans Required
w 9Ge,
�
yes Not Applic. ❑
Nath South3G East
VALUATION
CWt—
GAS
ELECTRICWATER
PUBLIC
LICENSEEXPIRES
PHONE
SlzeofParcel �c)
ZgpeClassificat' n
�„�-
Residential
UTILITIES
PRIVATE ❑
SEWER
public ❑Private
I hereby certify that I have read and examined this application and have read the "NOTICE" provisions included on
reverse side, and know the same to be true and correct. All provisions of laws and ordinances governing this type of
commercial ❑
4.
ADDRESS
thority to violate or cancel the pr visions of any other state or local law regulating construction or the performance
ZIPType
t.
upanc
Sprinklered
OWNER OR AGENT DATE
Mach.
SPECIAL APPROVALS
SPECIAL CONDITI : (SEE REVERSE SIDE FOR NOTICE)
PRELIM. FINAL DATE
I
❑Yee ❑No ❑Req'd.
Env. Health
DESIGNER
PHONE
New Const. ValuationN
emodeled Valuation
Total Bldg. Floor Area
Planning
Modular!
5
ADDRESS
MFG. Home
ZIP
Floorp Upper Floors
Garage/a
Greenhouse
CHANGE OF USE FROM
TO
Cover D6*
Unc9v.
Fin. Basement
Unfin. ent
6.
TYPE
No. Bats No.
Floors
No. FI Rooms
No. Dwellings
l
9 NEW ❑ ALT. ❑ AWN. 13 RPL. ElMVE.
Z
%. OF ❑OTHER
WORK Z BLD. ElPLMB. ❑ MECH. ❑ M.H. El POOL
Certifi.ofExempt.
Required
Yes❑ No❑
Number
or Variance
Received
Yea ❑ No ❑
DESCRI E WORK
8•
,
Shorelines/ Flood Hazard
Plans Required
w 9Ge,
�
yes Not Applic. ❑
Received el
VALUATION
I SOURCE
OF
GAS
ELECTRICWATER
PUBLIC
SEWAGE
SEPTIC ❑
Ownership
FEES COLLECTED
9.
UTILITIES
PRIVATE ❑
SEWER
public ❑Private
I hereby certify that I have read and examined this application and have read the "NOTICE" provisions included on
reverse side, and know the same to be true and correct. All provisions of laws and ordinances governing this type of
work will be complied with whether specified herein or not. The granting of a permit does not presume to give au-
Building
thority to violate or cancel the pr visions of any other state or local law regulating construction or the performance
of construction. SEE REVERS DE FOR REQUIRED INSPECTIONS
Plumbing
SIGNATURE OF APPLICATION
OWNER OR AGENT DATE
Mach.
SPECIAL APPROVALS
SPECIAL CONDITI : (SEE REVERSE SIDE FOR NOTICE)
PRELIM. FINAL DATE
Go,, ! -'r L)IC
Plan Check
Env. Health
�"°
SEPA
Planning
Modular!
MFG. Home
Fire
Prevent.
Engineer
Other (Specify)
-P,as tla
Oftz
Utilities
TOTAL $
SEPA
WHEN MACHINE VALIDATED IN
Plana
PERMIT IS NONTRANSFERABLE
THIS BECOMES A PERMIT.
Exam.
PERMIT IS NULL AND VOID IF WORK HAS NOT COMMENCED
Tech�ng IN 180 DAYS— pERM1T�(3 6 z * 4 3 9.O O fotAl
'�. DATE EDS 3 - 8 3
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Tech�ng IN 180 DAYS— pERM1T�(3 6 z * 4 3 9.O O fotAl
'�. DATE EDS 3 - 8 3
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