2006, 12-22 Permit App: 06004946 Wabo InspectionSpokanelle
1_•. Va y
Community Development
Permit Center
11707 E Sprague Ave, Suite 106
Spokane Valley, WA 99206
(509)688-0036 FAX: (509)688-0037
www. spokan eva11 ey. ori
Safety Inspection
Permit Application
PERMIT NUMBER:
PERMIT FEE:
Adult Family Home-WABO
n Fire/Water/Vehicle Damage
❑ Other:
SITE ADDRESS OS 5. 17/4e,eim
kx y /tY,.9
ASSESSORS PARCEL NO: LEGAL DESCRIPTION:
Building Owner:I'
p
Name: l�t/l 1,l, i4 iv L , -DA I.
Address: 1 I f I 5 I J 0p if, �,/ ,
/iii4.
City: �i�ii/A
Zip: �j/�1.�i�
1/i, 1 i
Phone: g i
t;7,...
Fax:
._7(.)
Sk 7) Fax: ,94 162
Contact Person
Name: kp °wI)S
Phone:
Contractor:
ow
DIMENSIONS:
# OF STORIES:
Name:
MAIN FLOOR TO SQ.
FTG:
2Nu FLOOR SQ. FTG:
Address:
IMPERVIOUS SURFACE
AREA:
FINISHED BASEMENT
SQ. FTG:
City:
State:
Zip:
Phone:
Fax:
HEAT SOURCE:
Contractor Lic No:
Exp Date:
City Business Lic. No:
D -scribe tlie scope of work in de 11:Cost of Project: $
v LA/Ota -C-1)Ma-d ) -4t YAC /%A�, �� - '
*************Th f ll in MUST be complete• (write N/A if not applicable)**********************
Q e o
HEIGHT TO PEAK:
ow
DIMENSIONS:
# OF STORIES:
TOTAL HABITABLE SPACE:
MAIN FLOOR TO SQ.
FTG:
2Nu FLOOR SQ. FTG:
UNFIN BASEMENT SQ. FTG:
IMPERVIOUS SURFACE
AREA:
FINISHED BASEMENT
SQ. FTG:
GARAGE SQ. FTG:
DECK/COV. PATIO SQ. FTG:
30% SLOPES ON
PROPERTY:
# OF BEDROOMS:
CONSTRUCTION TYPE:
HEAT SOURCE:
SEWER OR SEPTIC?
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. 6) Plans or additional information may be required to be submitted, and subsequently approved before
this application can be,.processed.
i
Signatur
Method of Payment:
❑ Cash
Bankcard #:
Authorized Signature:
REVISED 8/25/2005
❑ Check
❑ Mastercard 0 VISA
Expires: VIN#:
6
APPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2003 IBC 310 (WAC 51-50) and 2003 IRC 110 (WAC 51-51)
APPLICATLON CvIUMSER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
/ SECTION 1— PROPERTY INFORMATION
SrrE ADDRESS: i�j/l b7 ��/1%/P � ('JJ,J// / ASSESSORS TAX/PARCEL #:
SECTION 2 - APPLICANT INFORMATION
PROPERTY OWNER NAME:
LICENSEE NAME (u DIES: • f �� i C17 J ✓J t� Z)S
SECTION 3 — FLOOR PLAN
DAYTIME PHONE: .2•T.7F` 7/
DAYTIME PHONE: g e. -� 8 /%_i
A complete floor plan must include 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)
CARR
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SECTION 4— DISCLAIMER/SIGNATURE BLOCK
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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 requesting or
I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I further
certify that I am in the process of making an application to the Department of Social and Health Services for an adult family home license and that I
have also made application to the applicable jurisdiction for the appropriate license(s) to conduct such 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, including 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 the
jurisdiction as a part of applies
❑ PROPERTY 0 APPLICANT
LICENSEE
id /W106
DATE:
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