2004, 05-05 Permit App: BLD-04-04267 MH Replacement*Mane
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: Jam/ d / / ,elm ; ,(r r 41"775
Assessor's Tax Parcel Number(s): ,575-493/-? . o/3a
Legal Description:
PERMIT DESCRIPTION: /l c/ ./ C e J /V w % o r /1-1. /p
EIBuilding Permit IDChange in Use ❑ Grading ❑ Manufactured Home
❑ Tenant Improvement ❑ Fire Safety ❑ Other
❑ Relocation
OWNER/APPLICANT INFORMATION
❑
Owner: 4/<, , er,r y i
Phonevi r/ 7rc -znt Fax: ,574.r c
Address: fa, yc 76
frea -1Ln y9029
Cityo , ,State / wA lA/so CodeG'a 1 City
❑ Contractor: /4 K set xt ❑ Architect:
Phone: cfY- 47c z Fax: Phone: Fax:
Address: Address:
❑ Applicant:
Phone:
Address:
Fax:
State Zip Code
City
State
WA State Contractor License #:
Zip Code
City
Contact:
State Zip Code
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK
DIMENSIONS:
# OF STORIES:
MAIN FLOOR TO SQ. FTG:
2m-' FLOOR SQ. FTG:
UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG:
GARAGE SQ. FTG:
DECK/COV. PATIO SQ. FTG:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
HEAT SOURCE:
# OF BEDROOMS:
TOTAL HABITABLE SPACE:
IMPERVIOUS SURFACE AREA:
COST OF PROJECT:
30% SLOPES ON PROPERTY:
SEWER OR ON-SITE SEPTIC
SYSTEM?
MANUFACTURED HOME
Width: ) ' ' Length: /.
Manufacturer: ('„ r; n/Li;am ;rs'-
Year: 7 A/
Pit Set: /Y
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler: # of Heads: Fire Alarm: Paint Booth:
Tent: Fireworks Display: Blasting: Date/Time:
Valuation:
Above/Underground Storage Tank Size.
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner: Phone: Fax:
Address:
City State
Inspector: Phone: Fax:
Address:
Zip
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING ❑ CONCRETE
Firm Name:
❑ REINFORCEMENT
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 to the property owner.
Print Name Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash [i --Check ❑ Mastercard ❑ VISA ❑ Other
Bankcard #: Expires: VIN#:
Authorized Signature:
Department of Labor & Industries
Factory Assembled Structures Section
INSTRUCTIONS:
MANUFACTURED/MOBILE HOME
ALTERATION PERMIT
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
Do not •
complete
shaded
areas
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p121wner , last name
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" Address
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Serial NumberW/7 HUD Number(s)
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first name
Installer/Contractor/Dealer
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At
Day time phone
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Date ,.
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City
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Phone '
(52:47 —5,14'11/-47
State ZIP
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7 7/
Contractor's registration number
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S State ZIP+4
Place tee 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
a 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
- ill Inspection as part of a mechanical installation
(cut truss/floor joist, sheet rocking)
LiReroofs (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 structuralehanges.(may require a plan review)
Fire Safety c/Cyj ..„---
Serial No.
SerialNo.
Place fee amount in proper box
Electrical
Heat
PounnidiPtiOner 1; -
Furnace Installation (gas or electiic).".
Wood Stove (if ariplicable) ' •
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
_siPlan review
Reinspection - - - -
Insignia
Other
Original Pennit'
Note: This permit expires one year after date of purchase. (Non-refundable)
ii. Work 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
e Signature of applicant or authon zed rspresentanve
FEES DUE $ 90 cX
7.,e/ • /7 2. •
i D Request approVed : 'or ,Q RecMeet 'denied because of snecifie Violations of Washington rules and regulations.
It Violations must be corrected and reinspection requested Within 20 days of the notice of violation date: Failure to comply
at may result in penalties' per chapter 43.22 ROY.: : Al! violations noted are shown on art "Alteration/Factory Permit
A •„
: Continuation Forth”. -. '• ': : „
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EJ Inaoiled:are forms required Which Must be completed and foes subinitted*for6reinSpeMiOn...,
ftDate Area office in,P3FIW:: 7 7
,„ Total pages
F622-036-000 mfgd/mobile home alteration pemnt 11-02 White -Olympia Canary -Inspector Green -Contractor Pink -Purchaser Goldenrod -Purchaser
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