2004, 03-03 Permit App: BLD-04-03678 MHSpokane
Valley
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:
Asessor's Tax Parcel Number(s):
Legal Description:
PERMIT DESCRIPTION:
❑ Building Permit ❑ Change in Use
[I Relocation ❑ Tenant Improvement
❑ Grading
Fire Safety
Manufactured Home
Other
OWNER/APPLICANT INFORMATION
❑ Owner: ,-.1ohr )dinelJn `%111 `?J I1 Applicant:
Phone: 9&7-)1WS Fax: �n Phone: Fax:
Address: c90(0.30) So 11fsc Address:
Cj L' Ewiicus ()id G rfl7
City State Zip Code City State Zip Code
❑ Contractor:
Phone: Fax:
Address:
City
State
WA State Contractor License #:
Zip Code
❑ Architect:
Phone:
Address:
Fax:
City
Contact:
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:
30% SLOPES ON PROPERTY:
SEWER OR ON-SITE SEPTIC
SYSTEM?
MANUFACTURED HOME
Width:
Manufacturer:
Lencth: jy 4
wk ted
Year: cJ o2 Pit Set:
RELOCATION
Previous Address: 1911 j , Q
Proposed Use:
FIRE SAFETY
Fire Sprinkler:
Tent:
# of Heads: Fire Alarm:
Paint Booth:
Fireworks Display: Blasting: Date/Time:
Valuation: 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
El BOLTING ❑ CONCRETE
Firm Name:
I-1 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 L p Cir1 cZEISignature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash
Bankcard #:
Authorized Signature:
❑ Check ❑ Mastercard
❑ VISA
Expires:
VIN#:
Other
03/03/2004 14:27 FAX 509 477 4703
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0003
This site plan is being submitted for the purpose of
obtaining a building permit and is a true and correct
representation of the proposal. All known property
lines/dimensions, curb lines, structures and easements
have been Identified. Atso indicated are wetlands,
bodies of wa r, st ep lopes or other critical areas.
Signed' Cy'1�
Date
ADDRESS 14-1-25.. t\-) Cir tJ .I
ZONE 1
ROAD WIDTH 50
FRONT 3D FLANKING
COMMENTS
REVIEWED
CLiC A'77 A7M pore Gil
Department of Labor & Industries
Factory Assembled Structures Section
INSTRUCTIONS:
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.
MANUFACTURED/MOBILE HOME
ALTERATION PERMIT
Do not
complete
shaded
areas
Owner. Last name _
1 L/.i f"
first name
Address
Day time phone
( )
Date
City State ZIP
Installer/Contrar/Dealer
Address .• •
'l
City
1Contractor's registration number
State ZIP+4
Serial Number(s)
HUD Number(s)
Place fee 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
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
L1Inspection as part of a mechanical installation
(cut truss/floor joist, sheet rocking)
Reroofs (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 structural changes (may require a plan review)
Fire Safety
J
Serial No;
Serial No:
Place fee amount In proper box
Electrical
Heat pump
Air Conditioner
Furnace Installation (gas or electric) d Z
Wood Stove (if applicable) N W O
Pellet Stove (if applicable) N '�
Gas Room Heater _ ``'
Gas Decorative Appliance (if applicable) H
Range: changing from gas to electric U
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
Plan review
Reinspection - - - -
Insignia
Other
Note: This permit expires one year after date of purchase. (Non-refundable)
blWork is completed at this time. An inspection is requested.
Work is NOT completed at this time, I will call .den ready.
Make check payable to: Dept. of Labor & Indus
FEES DUE $
uesta
V10 ati00 Mil
may result in
ontinuatiof'
..............
ignature of applicant or authorized representative
d and reltspect'►oni re
r -chapter -43.22 R('W
ecati a car` specific viiolat ons•of VS�ashtn ton rue apt# regulations
nested within 2a days of the't otice of tilotat on date. Faure to comply
.411 violations noted are shown on an "Alteration/Factory Permit
uiretl��iclt izi�ia
...............................
-006.41.1
......................
F622-036-000 mfgd/mobile home alteration permit 11-02
Total page
White -Olympia Canary -Inspector Green -Contractor Pink -Purchaser Goldenrod -Purchaser