1984, 09-18 Permit App: 00002363 Residence r 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) i (first) (m) Department Use Only
`\i fi c y Luft 1 0..A.� Res. Comm
2 Project Address(not Mailing rens)or Road Name Space Zip
3 City/Community State Subdivision/Plat Name
rn I i blp ill i'r A-PP _
4 Assessor Parcel No. Lot I BlockV
* * * DEPARTMENT USE ONLY * * *
VS,—\ ti —\(z 0
5 Sic Code - Zone Act.ff Zone Project No.
6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage
I I _ i %-- 01 . 9s-4 i
7 Set Back-Front /
I(L)S-1 1 (R)S 2� i I Rear Census Tract 1 Module No. Initials '
* 16 Architect Firm Name f Street Address *
Zip City State fl Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name t Street Address
tr
F-Ii l<�0,�1, co-,c, tL�.vA:,-u...-- k Lyett?ti CA"—•
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Zip City State Phone t
ck4k ee'1—) C>1/4-t 5 CAC,$.AA 14t.Q-c�'., W L N.. ( ) C'2 --"�c>( c
Contact Person License No. Phone If different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace ❑ Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move
14 Describe 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
( )
Add itigoal I Information
&41 - .5 -7Ceis
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 ❑ Commercial; ❑ Residential
W.1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION#
Conditions/Comments:
❑ Planning/Zoning: ❑ Commercial; ❑ Cert.of Exemption; El Frontage;
N.721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU,variance,zone change;shoreline; El fence;
Cl Other
Conditions/Comments:
Engineers: Cl Commercial; ❑ Residential; ❑ Flood Plain; 40,
N.811 Jefferson ❑ drainage g/new access/approach; ❑ fence;
CIroad improvements J
Conditions/Comments:
❑ Utilities:
N.811 Jefferson
Conditions/Comments:
Other:
❑ Plan Exam
Fire Prey.
Conditions/Comments:
a
c
C
Project Representative Telephone
CD
Agencies Performing Special Inspection:
c 1.
0 O
E 2.
y o
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Coeur d'Alene Trusses. Inc.
655 WEST CLAYTON AVENUE • COEUR D'ALENE, IDAHO 83814 • (208) 667-6481
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