2004, 05-13 Permit App: BLD-04-04339 MHj
BUILDING PERMIT APPLICATION WORKSHEET
City of Spokane Valley Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone: (509) 688 -0036; Fax: (509) 688 -0037
REQUIRED SITE INFORMATION
Street Address: / 74 2
77S bA Z-11262�
Assessor's Tax Parcel Number(s):
/:,71 Ds)Gtidrto c9
PERMIT DESCRIPTION: 5d /"ih‘,,
Legal Description:
E Building Permit
❑ Relocation
H Change in Use n Grading Manufactured Home
(— Tenant Improvement E Fire Safety U Other
OWNER/APPLICANT INFORMATION
❑ Owner:oh /��r�
Phone: /7-6'f/3 Fax:
Address: /7/6" 6/
City State
Zip de
H Contractor:
Phone:
Address:
Fax:
City
State
WA State Contractor License #:
Zip Code
n
n
/.55')/ #edou�a os LL
Applicant: 1, y‘„, /'1 » r
Phone: 75 -_�2 Fax:
Address: j5-/ r 4;4&,
it/
Architect:
Phone:
Address:
State
e %3 7
Zip Code
Fax:
City
Contact:
State
Zip Code
PERMIT /BUILDING INFORMATION
TO PEAK:
/ / t
DIMENSIONS:
i/ X X� <� ?
# OF STORIES: /
MAIN FLOOR TO SQ. FTG:
2' FLOOR SQ. FTG:
UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG:
GARAGE SQ. FTG:
DECKICOV. PATIO SQ. FTG:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
HEAT SOURCE:
# OF BEDROOMS: A?
TOTAL HABITABLE SPACE:
IMPERVIOUS SURFACE AREA:
COST OF PROJECT:
30% SLOPES ON PROPERTY:
SEWER OR ON -SITE SEPTIC
SYSTEM? /'ub /iZ 5e -t_
r
MANUFACTURED HOME
Width: 2& ( - `7 Length:
Manufacturer:
Year: 'Zoo 3 Pit Set: %5
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler:
Tent:
Valuation:
# of Heads: Fire Alarm:
Fireworks Display: Blasting:
Above /Underground Storage Tank Size:
Paint Booth:
Date/Time:
WASHINGTON STATE NON - RESIDENTIAL ENERGY CODE
Plans Examiner: Phone: Fax:
Address:
City State
Inspector: Phone: Fax:
Address:
Zip
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING n CONCRETE
f i REINFORCEMENT
Firm Name: Phone:
Inspector(s):
Fax:
❑ WELDING
DISCLAIMER
The permitee verifies, acknowledges and agrees by their signature that: 1) If this permit is for construction of or on a
dwelling, the dwelling is /will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the
property owner. 3) The signatory is the property owner or has permission to represent the property owner in this
transaction. 4) All construction is to be done in full compliance with the City of Spokane Valley Development Code.
Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) This City of Spokane Valley
Permit is not a permit or approval for any violation of federal, state or local laws, codes or ordinances.
Ownership of resulting development rights granted by any issued permit inure tom the pro•ert o ner.
Print Name �Gc cy � Sc3Y�
Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash ❑ Check ❑ Mastercard
Bankcard #:
Authorized Signature:
❑ VISA
❑ Other
Expires: VIN #:
(-S-POKANE COUNTY UTILITIES /SEWER & GFC
1026 W. BROADWAY, SPOKANE, WA 99260
(509) 477 -3604
Received From
Site Address /9
Account Number
Dollars $
m1s.1tJ
/2,1 6-2)
HOW PAID
CASH
CHECK
MONEY
ORDER
RECEIPT No.
j No. 04650
Date 6/ ( 20
of Ulf '7 /
By
ADD
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ROAD WIDT
FRONT
COMMENTS
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. Also indicated are We
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