1984, 08-13 Permit App 1723 MHBUILDING 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)
er2 C& C
(first)
s 11-)
(m)
11
[bperiment Only
Ras.V, I Comm
2 Project Address (not Mailing Address) or Road Name I
6 1
Space
Zip
9� I
3 GtylCommunity,
6
4 r Parcel No.
State
Lot
SubdNisionl Plat Name
W O
Block
DEPARTMENT USE ONLY + + t
5 Sic Code
Zone Act.#
Zone
(4-
Project No.
`
- 6 Dwell N
No. of Buildings
Sq. Ft. /Acre
1(Zi= ILALI�
Depth
Frontage
7 Set Beck- root
(L)S-1
( )S-2 Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
city
State
Phone
1 1
Contact Person
Phone if different than above
)
Contractor Firm Name
APG
Street Address
It
State
W CA.
Phone
PhoneK
NL) 1 6/-- %
Oontac,IU2 n
License No.
Phone if different than above
)
6 wnerl ent (If different than el am;)
Business Address
9 Zip
City
State
Phone( )
12 Review Required
Plan Check (YIN)
Other(Y/N)
SEPA
Exempt (YIN)
Date
15 Type Work
❑ Bldg
❑ Fire
§]f MH
❑ Demo
New
❑ Add/Alter
X Replace
❑ Move
❑ Other
14 Describe Work
F
10 Applicant Name
St r t Address
Z�
11 Zip
Cit
State
1-)
Phone
609 1 ��-
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
t Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
I nls Is not a Permit
❑
(Standard unless
otherwise Indicated)
Fast Track
(Indicated approvals required In either "release- or 'release with conditions -
space prior to permit issuance.)
❑
Early Start
Release
1w/cond17Ho17d2
_
Release
Environmental Health
❑ Commercial; 17�Yhesidential -
W. 1101 College
Room 200
❑ New Construction; ❑ Bldg alteration/addition D
❑ Additional structure; y 77
APPLICATION 11
Conditions/ Comments:
❑
Planning/Zoning:
❑ Gtommercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
❑
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/ approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
0
1.
E
2
o
C
3.
t Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
W
REV. KEALTH
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f
For Spokane County Health District
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REV. KEALTH
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f
For Spokane County Health District
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