2005, 07-18 Permit App: 05002401 Repair Water DamageBUILDING PERMIT APPLICATION WORKSHEET
City _,p kane Valley Community Development Department
TO
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone: (509) 688-0036; Fax: (509) 688-0037
ED
INFORMATION
Street Address:
ds S . EVG' (2_i 12een f cl . VSOiz
Assessor's Tax Parcel Number(s):
Legal Description:
PERMIT DESCRIPTION: Rp !acQ
❑ Building Permit
❑ Relocation
CLA,,/ 41) +f
❑ Change in Use ❑ Grading
Tenant Improvement ❑ Fire Safety
❑ Manufactured Home
Other /e%oq;
OWNER/APPLICANT INFORMATION
E Owner: S us a/' Fianna e 1— ❑ Applicant:
Phone: 9017-(Py06 Fax: 6,),3-I 7 7.7 Phone: Fax:
Address: I 0 S S eUe r5 r2trrt ied Address:
Spe /40,e Valley (Ai A- .79v37
Cit9 State Zip Code City
❑ Contractor: �' t B k, i ) de - ❑ Architect:
Phone: Lica -S4-76/(1 Fax: Phone: Fax:
Address: Address:
State Zip Code
t \2
City
State Zip Code
City
WA State Contractor License #: C.D.Pw(i DP3c) 7LXi2Contact:
Spokane Valley Bus. Liscense #:
Contact:
C kkeS
State Zip Code
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK:
DIMENSIONS:
# OF STORIES:
MAIN FLOOR TO SQ. FTG:
2' 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: �r-- (> C.)
.i'f �- ���
30% SLOPES ON PROPERTY:
SEWER OR ON-SITE SEPTIC
SYSTEM?
MANUFACTURED HOME
Width:
Manufacturer:
r•
Length: ( Year: Pit Set:
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:
Address:
Phone:
Fax:
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 inu,
to the propert ner.
Print Name SLSc4'► (i r w.t' r Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash �J Check El Mastercard I:11 VISA ❑ Other
Bankcard #: <
Authorized Signature:
Expires:
VIN#:
Project Address:
PLUMBING PERMIT APPLICATION
Phone: (509) 688-0036; FAX: (509) 688-0037
For Inspections, Cali (50,9if43054
1105 S EVei'C s2�
Owner. k-kS,— 14rvn-e—
Mailing
Contractor. le,\ KGs I v 1_i n j
Mailing Address: .X-7 C ( �' 1-h
Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
1zllcce
/2,�kcc.fe !,y ISS .
Permit Use: - (?cf i + k..%e �rr. -er
,p Phone (Daytime Contact): Co. e 2.1f-' yi Z�
Address: 1) 05 S. E�2 l2 eP� k,t 1 eptict D Oct It?, wig- .7903
7
City State
Lic
ense
Zip Code
I-ii.Cf`N
City
Phone*. `j - 3 7 73
S CICCel"‹� uJA- 90Z
State Zip Code
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
DESCRIPTION OF WORK
# OF UNITS
X
COST .
=
TOTAL AMOUNT
1
TOILETS
WATER CLOSET, BIDETS
X
$6.00
=
2
URINALS
X
MOD
=
3
TUBS
X
$6.00
=
4
SHOWERS (PER TRAP)
BATH, STALL, ON-SITE BUILT
X
$6.00
=
5
SINKS
LAVS/BASINS, BAR, FLOOR, KITCHEN,
LAUNDRY, UTILITY, JANITOR, PHOTO,
X-RAY, FOOD, PREP/CULINARY MEAT
X
$6.00
=
6
DISHWASHER
X
$6.00
=
7
CLOTHES WASHER
X
$6.0D
=
8
GARBAGE DISPOSAL
X
$6.00
=
9
WATER SOFTENER
X
$6.00
=
10
ELECTRIC HOT WATER TANK
NOTE IF GAS, SEE MECHANICAL
I
X
$6.00
=
(.0 , C ()
11
FLOOR DRAINS
AREA, CASE, COIL, TRENCH, CONDENSATE
X
$6.0D
=
12
ROOF DRAINS/OVERFLOW
DRAINS
X
$6.00
=
13
FOUNTAINS, DRINKING
X
$6.00
=
14
WATER PIPING/DRAIN-IN WASTE,
VENT, PLUMBING, REVERSAL
NSTALLATION, ALTERATION, REPAIR,
REVERSALS
X
$6.00
=
15
SEWAGE EJECTOR
GRINDER, SUMP PUMP
X
$6.00
=
16
WATER USING DEVICE
ICE AN/OR COFFEE MAKER, HOSE BIB,
STEAMER
PROOFER, CARBONATOR, SWAMP COOLER
X
$6.00
=
17
CROSS CONNECTION DEVICE
VACUUM BREAKER, CHECK VALVE,
AND R.P.B.P.D. FOR VATS, TANKS, BOILERS
X
$6.00
=
18
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
X
$6.DD
=
19
MEDICAL GAS (per outlet)
NITROUS, OXYGEN
X
$6.00
=
20
MISCELLANEOUS PLUMBING
FIXTURE
X
$6.00
=
21
PRIVATE SEWAGE DISPOSAUSYS
X
520.00
=
22
INDUSTRIAL WASTE
INTERCEPTOR
X
515.00
=
METHOD OF PAYMENT:
0 CASH i CHECK
DATE:
SUBTOTAL
0 VISA 0 MASTERCARD
PROCESSING FEE
535.00
EXPIRES:
TOTAL PERMIT FEE DUE:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: