2005, 02-23 Permit App: 05001007 Change of UseSc. rf Kane , ity of Spokane Valley Community Development Department
�. Building Division
11707 E. Sprague Avenue, Suite 106
40
Vale ne: (509) 688-0036; Fax: (509) 688-0037
Spokane Valley, WA 99206
YFT)
ibb
BUILDING PERMIT APPLICATION WORKSHEET
'REQUIRED SITE INFORMATION
Street Address: / ` 746 E / c e A v -e 5 11,a /Ly 77 2/h
Assessor's Tax Parcel Number(s): <4 5 . / Z - 3 `/` 6 %
0 ikfLik-fl
C1;,ye /e lie / 61 C -f5 -e
Legal Description:
PERMIT DESCRIPTION:
7 Building Permit
Relocation
n Change in Use n Grading
,tm- dL1vu
r ra S /-, /052
(^ Manufactured Home
Tenant Improvement Fire Safety [1 Other
OWNER/APPLICANT INFORMATION
Owner: /(4%-r /0 4+ /C (Cr 4; 5 (l Applicant:
•Phone:
Address:
Phone: Z M —756 Fax: Y//2
dress: /q/06 E aaye
5/0 c -1)-e (A7(4y 1-r//� `� '27.‘
City State Zip Code
7 Contractor:
Phone: Fax:
Address:
City
State
WA State Contractor License #:
Zip Code
C
Fax:
Contact:
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK:
DIMENSIONS:
# OF STORIES: /
MAIN FLOOR TO SQ. FTG:
2N° 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?
L
MANUFACTURED HOME
Width:
Manufacturer:
Length: Year: Pit Set:
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler: # of Heads: Fire Alarm:
Tent:
Valuation:
Paint Booth:
Fireworks Display: Blasting: Date/Time:
Above/Underground Storage Tank Size:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
Phone:
Fax:
City
Inspector: Phone:
Address:
State
Fax:
Zip
City
State
Zip
SPECIAL INSPECTIONS
fl
BOLTING n CONCRETE
Firm Name:
(-I REINFORCEMENT
Phone:
Inspector(s):
Fax:
n 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)
[l Cash (l Check (l Mastercard ❑ VISA ❑ Other
Bankcard #: Expires: VIN#:
Authorized Signature:
.`;
4
lel--tr\ALLJ,i-k_ ak_c(
230" cAlLoAt_ -
-1-;:ukt 'GA ktfr_
4.SOuN
v
5 Cape
514?0,4 /Cc- 71.0r5
• 51411j4Pe24/
61/:
/0 /6
ire el,;,1 t4
/c
eP Ze 010,0 ‘140
REQUEST FOR INSPECTION- Adult Family Home
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION 1 - PROPERTY INFORMATION
SITE ADDRESS: / 4'/O E , /0:2
SECTION 2 - APPLICANT INFORMATION
ASSESSOR'S TAX/PARCEL #: 4L5-7 Z - /
PROPERTY OWNER NAME: /tief-�d ir '/t6/> F/ham C 6i .-7 / .S DAYTIME PHONE: (fid ?) 3-77—M
LICENSEE NAME (ff oIFFERErrr): / DAYTIME PHONE:
SECTION 3 — FLOOR PLAN
A complete floor plan must indude all sleeping rooms, identified by number (#1, #2, #3 etc.) and all components for
exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the information fumished by me is true and correct to the best of my knowledge, and that I am authorized by
the owner of the above premises to request Inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Departrnent of Social and Health Services and the jurisdiction for the appropriate license(s) to conduct sudi business at this
location. I further agree to hold harmless the jurisdiction conducting such inspections at my request as to any daim (induding costs, expenses, and
attomeys' fees incurred in the investigation of such daim), which may be made by any person, induding the undersigned, and filed against the
jurisdiction, but only where such daim arises out of the reliance of the jurisdiction, induding its officers and employees, upon the accuracy of the
information supplied to riscjiction as mart of theapplication.
NAME/TITLE:
Of PROPERTY OWNER ❑ APPLICANT 0 LICENSEE
DATE:
q- 2i -0c
SECTION 5 - INSPECTION CHECKLIST
Home licensed (or applying for license) on or after July 1, 2001
SLEEPING ROOMS
Sleeping Room #1 ❑ S NS1 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #2 0 S NS1 ❑. NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #3 0 S ,i NS1 0 NS2
Bedroom door is operable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #4 0 S 0 NS 1 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #5 ❑ S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #6 0 S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily operable from the inside
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
Sleeping room window has a maximum sill height of 44"
GENERAL
Bathroom doors are openable from the outside when locked
Smoke alarms are installed on all levels of the dwelling
All smoke alarms are audible in all parts of the dwelling upon activation of a single device
Access road and water supply approved by Fire Department
,. PASSED
INSPECTOR: E9�''�`J�
YES NO
O 0
O 0
N 0
N 0
0❑
❑
• 0
0❑
4 0
0
N 0
"N 0
• 0
N 0
o ❑
O ❑
❑ ❑
❑ ❑
❑ ❑
❑ 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
O 0
ja 0
0
• 0
0 CORRECTIONS REQUIRED 0 PERMIT REQUIRED
2I"0�
DATE: t--}