500 E. Main, Othello, WA 99344  (509) 488-3302

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Project Address:

Owner:___________________________________Parcel#_______________________________

Project Description:______________________________________________________________

Square Footage:___________________________Building Use:___________________________

Lot#_________________Block#_______________________in_____________________Addition

*Contractor:________________________________________*St. Lic.#_____________________

Project Supervisor:__________________________________*City Lic.#_____________________

Address:__________________________________________Phone#_______________________

Fax#_____________________________________________*Contract Value:________________

*Design Professional of Record:_____________________________________________________

*Address:_________________________________________*Phone#______________________

*Information is not required, if the owner is the project supervisor.

Documents submitted with or prior to this application:

• SEPA checklist
• Accurate Site Plan
• Design Drawings
• HVAC Worksheets 
• Truss Plans/Engineering Work
• Fire Sprinkler Plans
• Storm Water Management Plan
• Right-of-Way Permit Application
• ________________________
• ________________________

I understand this permit is void if any information submitted is incorrect. 

I agree that construction shall conform with the plans, specifications, plan review conditions, and applicable codes of this project.  Permits presuming to give authority to violate provisions of the codes, ordinances or laws of the City of Othello shall not be valid. 

_________________________________________     ___________________________

Project Supervisor’s Signature                                                          Date