1986, 08-08 Permit App 00012556 MH-L)
DEPARTMENTAL REVIEW
Approved
p
Approvoval
Hold
Environmental Health Permit Number
1101 College Room
Room 200
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Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/ Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
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 true, correct, legal, and binding.
Owner's Signature Date
(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)
Owner's Name
Applican
Contractor/Agent
Contact
Architect/ Engine..
Lender
State
State
State
State
SHADED AREAS ARE FOR DEPARTMENTAL USE
License Number (Required)
FIRST MI
Phone
IProject Number
Business Phone
Address
Phone
Business Phone
(
Addres
Phone
Business Phone
(
Phone
Show tin Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
.Septic System (s) r
:VOW LAI OS:
fence*, Welk • • • •
Driveway(s) • • • : ; • ; .1
ilight•Of Way Width(t);
Nimes:Of • • ; • ;
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
''; HigtiOter Mark-
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Legal Description
• :
- PRE-SORTED
FIRST CLASS MA
_
U.S.-POSTAp
PAID -
SPOKANE,WA
-PERM it No: 1155-
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