2009, 06-18 Permit App: 09001805 Tear Off, ReroofCommunity Development Department
Permit Center (Staff Use Only)
Sp' OF 1lLlne
11703
Spokane East Sprageyue Avenue, Suite B-3 UMBE
PERMIT NR: �� C-
Vall, WA 99206 I J
Tel: (509) 688-0036
Valleyk Fax: 50cen 688-0037 — �� 7S
Fermi ittor(obspokanevalley.orq
3\
REROOF CONSTRUCTION PERMIT APPLICATION
❑ COMMERCIAL RESIDENTIAL
SITE ADDRESS: )3 00i c 1 AL YJ O
ASSESSORS PARCEL NO.: LEGAL DESCRIPTION:
BUILDING
/�OWNER N]A,ME:c )</,'' 2. `P y�SC-HiMAR(
NAME: K\.A'2 L 1 1 v� � A. -I e "T�v K
ADDRESS:` !3 V C7 /� ]��it to Z D
CITY:,-. &G KA NfE / vA STATE: W �\
PHONE: 5o q— �Z.6— 42_7 ) FAX:
CONTACT NAME:
ZIP:
CELL:
PHONE: . FAX: CELL:
CONTRACTOR NAME: j.A0 dv ir(N
MAILING ADDRESS:
CITY: STATE:
Zip:
PHONE
FAX: CELL:
CONTRACTOR LICENSE No.:
EXPIRES: CITY BUSINESS LICENSE NO.:
DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE:
—TY/Az. a 14P Po6fs
Tear Off ❑ Overlay
n
TOTAL COST OF PROJECT: $ ` Z 6,5-00 —
DISCLAIMER
The permitted verifies, acknowledges and agrees by their signature that: 1) if this permit Is for construction 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) The City of
Spokane Valley permit is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additional
Information may be required to be submitted and subsequently approved before this application can be processed.
Method of payment: ❑ Cash
Bankcard #:
Authorized Signature:
0 Check
Date: ..6 j1409
❑ Visa ❑ Mastercard
EXP: VIN#:
Effective October 28, 2007
C:\Documents and Settings\southside00\Local Settings\Temporary Internet
Files \Content.I E5\KXM N W H E7\Reroof°/D20Construction%20 Permitbo20App.1 [ 1].doc
Page 1 of 1