2003, 10-21 Permit Application: BLD-03-02840 MH PlacementSikitZeN'
Valley
PERMIT APPLICATION WORK SHEET
SPOKANE VALLEY COMMUNITY DEVELOPMENT
BUILDING DIVISION
11707 East Sprague Ave Ste 106
Spokane Valley, WA 99206
Phone: (509)688 -0036 Fax: (509)688 -0037
REQUIRED SITE INFORMATION
STREET ADDRESS: 21.-11- I S N A D A T %` j
ASSESSOR'S TAX PARCEL NUMBER(S): 5 - 0 2- ) - - 6/0 ( 2 cock
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LEGAL DISCRIPTION: deA.414- IAN ler c r t /iro`/ e c
- ✓�iZ� �
4'/6S ,T F 2Y
PERMIT DESCRIPTION: Se 7tiAu6 /er/r.,f'r
® BUILDING PERMIT D CHANGE IN USE D GRADING
D RELOCATION
® SIGN D TENANT
JQ9.MANUFACTURED HOME
OTHER
OWNER / APPLICANT INFORMATION
OWNER: N LSI L- \/,,I/4 Cluj
PHONE: c?22 45-q S FAX:
ADDRESS: 44-i 5 %/ Actium.-
D CONTRACTOR:
PHONE:
D APPLICANT: rvl,
SAl, rvi
Yea of 40-e
fa — t
CITY,STATE, ZIP
etQl 2L 1
FAX:
ADDRESS:
CITY, STATE, ZIP
WA ST CONTRACTOR LICENSE #
PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
ARCHITECT:
PHONE:
ADDRESS:
CITY, STATE, ZIP
FAX:
CONTACT:
PERMIT /BUILDING INFORMATION
COST OF PROJECT:
BUILDING HEIGHT TO PEAK:
BUILDING DIMENSIONS:
NUMBER OF STORIES:
NUMBER of BEDROOMS:
FLANKING SETBACK:
FRONT SETBACK:
REAR SETBACK:
LEFT SETBACK:
30% SLOPES ON PROPERTY:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
MAIN FLOOR SQ FT:
2N0 FLOOR SQ FT:
UNFIN BASEMENT:
STRUCTURES ON PROPERTY: FINISHED BASEMENT:
CRITICAL AREAS: GARAGE:
CURRENT PROPERTY SIZE: COVERED DECK:
CURRENT PROPERTY USE: DECK:
CURRENT SEPTIC USE:
CURRENT WELL USE:
RIGHT SETBACK: IMPERVIOUS SURFACE AREA:
1
MANUFACTURED HOME SIGN
WIDTH: /
YEAR:
LENGTH: 4
PIT SET:
MANUFACTURER: R +`
SQ FT OF SIGN: HEIGHT OF SIGN:
# OF SIGNS: AREA OF EXIST SIGN:
TYPE OF SIGN:
RELOCATION FIRE SAFETY
PREVIOUS ADDRESS: E -C�-�
PROPOSED USE: 7-EAT & L--
FIRE SPRINKLER: FIRE ALARM:
PAINT BOOTH: TENT:
FIREWORKS DISPLAY:
BLASTING: DATE /TIME:
WA STATE NON - RESIDENTIAL ENERGY CODE
PLANS EXAMINER: PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
INSPECTOR: PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
SPECIAL INSPECTIONS
® BOLTING El CONCRETE ® REINFORCEMENT
FIRM NAME:
INSPECTOR(S):
PHONE:
® WELDING
FAX:
BUILDING STAFF USE ONLY
IS PUBLIC SEWER AVAILABLE: ® YES ® NO
0
IS PUBLIC WATER AVAILABLE: YES NO
IF YES: COUNTY CITY
IF YES, WHICH WATER DIST /IRR:
IS PROPERTY LOCATED WITHIN DESIGNATED STORMWATER CONTROL AREA: 0 YES 0 NO
IS THE PROPERTY LOCATED WITHIN ASA: 0 YES ® NO
PSSA: 0 YES ® NO
II DATE:
1
STAFF:
METHOD OF PAYMENT;
CASH CHECK
BANKCARD #; EXPIRES; VIN #
AUTHORIZED SIGNATURE.
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
iJ
Department of Labor & Industries
Factory Assembled Structures Section
INSTRUCTIONS:
1. Complete all spaces, including the signature box (marked with an X).
2. Draw a map on reverse side of WHITE copy only.
3.. Forward completed permit and fees to the nearest L &I office. See list on reverse.
4. Contact and schedule the inspection(s) with the same L &I office per the checklist.
MANUFACTURED /MOBILE HOME
ALTERATION PERMIT
permit
Owner last name
Address
first name
Day time phone
)
Do not
complete
shaded
areas
Date
City
State ZIP
Instiller/Contractor/Dealer
Phone
( )
Address
City
IContractor's registration number
State ZIP+4
Serial Number(s)
HUD Number(s)
Place fee
amount In proper box
Mechanical
Heat Pump
Air Conditioning
Furnace Installation (gas or electric)
Gas Piping
Wood Stove - --
Pellet Stove
Gas Room Heater
Gas Decorative Appliance
Range: changing from electric to gas
Gas Water Heater replacement
Water Heater: changing from electric to gas
Plumbing
Fire sprinkler system (also requires a plan review)
Each added fixture
Replacement of water piping system
Structural
Inspection as part of a mechanical installation
(cut truss/floor joist, sheet rocking)
Reroofs (may require a plan review)
Changes to home when additions bear loads on home per
the design of a professional (also requires a plan review)
Other structural changes (may require a plan review)
Fire Safety
Serial Noi::
Serral Nn ;<
Place fee amount in proper box
Electrical A ': i vIty s±` , 2003160216
Heat pump ?wt.. .6 ...t; ': �....
Air Conditioner . t=r x...e > ' °`;'';?;1
Furnace Installation (ghs bi ectnc) '
Wood Stove (if applicabl ).Y r
Pellet Stove (if applicable)
Gas Room Heater
Gas Decorative Appliance (if applicable)
Range: changing from gas to electric
Electric Water Heater replacement
Electric Water Heater replacing Gas Water Heater
Each added or modified circuit
Hot Tub or Spa (power from home electrical panel)
Replace main electrical panel
Low Voltage Fire/Intrusion Alarm
Fire Safety
Miscellaneous
Plan review
Reinspection - - -
Insignia
Other
Original Permit
No.
Note: This permit expires one year after date of purchase. (Non - refundable)
blWork is completed at this time. An inspection is requested.
Work is NOT completed at this time, I will call when ready.
Make check payable to: Dept. of Labor & Industries
FEES DUE
Request approved or Revues
tolatioins must be corrected and retnspectto
may result �n penalties per chapter 43 Z2 It
ontinuattol 1�� orm
are forms re
tore
Signature of applicant or authorized representative
dented be
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cause o spe+ fic violations of Washin ton rules and re ulattons;:i.
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d' ithin 2Q days of the notice of violation date k'ailu�re to comply
violations noted are shown tin an ".Mteratton/Factory Permit:;
W }IiC1[ Illt;st::be COfIT
rea >offiee
letetl and lees submitted before reinspec
is ctar::
F622- 036 -000 mfgd/mobile home alteration permit 11 -02
Total pages
White- Olympia Canary- Inspector Green - Contractor Pink - Purchaser Goldenrod - Purchaser