1983, 09-28 Permit 83A-9655 MHSIGNATURE OF
OWNER OR AGENT 7
SPECIAL APPROVALS
PRELIM. FINAL DATE
r LMIV PIUMC3tr1
APPLICATIO ERMIT
SPOKANE COUNTY - DEPART F BUILDING & SAFETY
NORTH 811 JEFFERSON / SPOKANE, WASHINGTON 99260 / (509) 456-3675
STREET ADDRESS
APPLICANT: COMPLETE NUMBERED SPACES — PRESS HARD TO MAKE 3 COPIES
1. .1172 v 1^'�
LOT
2. 11 e,
BLOCK
SUBDIVISIO
OWNER
3 Si• 1 NJ I N/�CF2'f(t�i
MAILING ADDR SS
If. i I2--04"
CON143 pR
4. �
ADDRESS
DESIGNER
5.
ADDRESS
6.
PHONE
LICENSE EXPIRES
PHONE
791-40
PHONE
ZIP
PARCEL NO.
°1- -1
LEGAL DESCRIPTION:
Actual Set Backs in Feet to:
North [South 1
Size of Parcel Zone ClassificationWest
Type Const.
Occupancy
Residential
Commercial ❑
Sprinklered
❑Yes El No ❑Req'd.
CHANGE OF USE FROM
7.
8.
TYPE [2<lEW
OF
WORK ❑ BLD.
W
DESCRIBE WORK �r
VALUAfr OI SOURCE
9. o OCO OF
UTILITIES
PHONE
ZIP
TO
❑ ALT. ❑ AD'N. ❑ ❑ MVE.
❑ PLMB. ❑ MECH. , M.H. ❑ POOL
(i4- )C ivo
GAS
ELECTRIC
❑ OTHER
PUBLIC
PRIVATE ❑
SEWAGE"
!Air
SEWER ❑
New Const. Valuation
Remodeled Valuation
Total Bldg. Floor Area
Main Floor
Upper Floors
Garage/Storage
Cover Deck
Uncv. Deck
Greenhouse
No. Baths
Certifi. of Exempt.
or Variance
No. Floors
Fin. Basement
Unfin. Basement
No. Fin. Rooms
No. Dwellings
Required
Received
YesE No❑
Yes Non
Number
Shorelines/Flood Hazard
Yes❑ Not Applic. ❑
Ownership
Public 0 Private ❑
I hereby certify that I have read and examined this application and have read the "NOT 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-
thority to violate or cancel the provisions of any other state or local law regulating construction or the performance
of construction. SEE REVERSE $IDE FOR REQUIRED INSPECTIONS
1-e:&1 �t ti
APPLICATION ��
DATE /
Env. I-fealth
Planning
Fire
Prevent.
Engineer
Utilities
SEPA
Plans
Exam.
Building
Tech.
so
SPECIAL CONDITIONS: (SEE REVERSE SIDE FOR NOTICE)
PERMIT IS NONTRANSFERABLE
PERMIT IS NULL AND VOID IF WORK HAS NOT COMMENCED
IN 180 DAYS
Plans Required C
Received 0
FEES COLLECTED
Building
Plumbing
Mech.
Plan Check
SEPA
Modular/
MFG. Home
Other (Specify)
TOTAL $
PERMIT NUMBER
WHEN MACHINE VALIDATED IN THIS SPACE,
THIS BECOMES A PERMIT.
09--25-B3
DATE ISSUED
PERMIT'N�. 5 z ci * 5 0. O 0 TOTAL