2003, 05-06 Permit App: BD-03-344 RemodelCity of
SPOKANE VALLEY
620- 003
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PERMIT #
BUILDING PERMIT APPLICATION
Box 1 OWNER - Th`Q;L;6
OWNER'S DRESS \L}/ ) CITY
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DESCRIBE JOB
JOB LOCATION gtoz( Lory
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THIS PROPERTY IS OWNED BY` SINGLE MARRIED
PARTNERSHIP CORP.
BOX 2 CONTRACTOR'S NAME
CONTRACTOR'S ADDRESS
PHONE
CITY
CONTRACTOR'S REG.# EXPIRATION DATE
(CARD MUST BE PRESENTED AND COPIED OR VEFFIED)
BOX 3 CONTACT PERSON OF PROJECT
PHONE
ADDRESS CITY ZIP
BOX 4 SEWER AVAILABILITY
WATER AVAILABILITY
BOX 5 ESTIMATED PROJECT COST $ EXISTING BLDG. VALUATION $
BOX 6 PROPERTY TAX ACCOUNT NUMBER
LEGAL DESCRIPTION
(IF NECESSARY, PLEASE SUBMIT A SEPARATE PAGE WITH THE LEGAL DESCRIPTION)
• CENSUS NUMBER LOT NUMBER
BOX 7 BUILDING SQUARE FOOTAGE (Existing / proposed)
3RD FLOOR / OTHER
BASEMENT UNFINISHED /
CARPORT / TOTAL
1ST FLOOR / 2ND FLOOR /
/ BASEMENT FINISHED
DECK / GARAGE /
HEIGHT TO PEAK OF BUILDING FT.
BOX 8 ( ) SINGLE FAMILY
( ) MULTIFAMILY (NO. OF UNITS
( ) COMMERCIAL / INDUSTRIAL
( ) TENANT IMPROVEMENT
( ) NEW CONSTRUCTION
( ) EXISTING STRUCTURE
TOTAL AREA OF PROPERTY SQ. FT.
IMPERVIOUS SURFACE SQ. FT.
BOX 9 PLUMBING FIXTURES (Including rough -ins) MECHANICAL APPLIANCES
PLEASE USE THE ATTACHED PLUMBING / MECHANICAL FORM FOR THE LISTING OF ALL APPLIANCES,
SYSTEMS, HEATING AND AIR UNITS, FIREPLACE INSERTS, WATER HEATERS, CONVERSION BURNERS,
LAWN SPRINKLER SYSTEMS, BACK FLOW PREVENTERS, ET AL.
BOX 10 Water Service meter size (if known) Also see BOX 4
BOX 11 Septic Tank — Not generally allowed in the City of Spokane Valley. For special circumstances contact
Your e r purveyor and the Health. District (See BOX 4) �' 4re s4 ;r iL f . /6,
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BOX 12 tS ret us m'cequfr a`�` SfreetTU Petmg& sewer,Aater, sidewalks, curb cuts. Contact the Public f/44J
Works Department.
I VERIFY UNDER THE PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE
ABOVE PREMISES TO PERFORM THE WORK FOR WHICH THE APPLICATION IS MADE.
OWNER / AGENT DATE (OVER)
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card:
Visa Mastercard ` _ — -- — Expiration Date
Print the name of the Holder Signature
OFFICE USE ONLY - PLEASE DO NOT WRITE BELOW THIS LINE
ZONE SETBACKS: FRONT SIDE REAR HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL DISAPPROVAL DATE
REMARKS
SEPA: EXEMPT NOT EXEMPT
FIRE DEPARTMENT APPROVAL DISAPPROVAL DATE
REMARKS
PUBLIC WORKS DEPARTMENT APPROVAL DISAPPROVAL DATE
TYPE OF JOB: NEW RESIDENCE RES. ADD/ALT
NEW INDUSTRIAL IND. ADD/ALT
NEW COMMERCIAL COMM. ALT/ADD NEW MULTIFAMILY NO. UNITS
MULTIFAMILY ADD/ALT TENANT IMP. ROOF OTHER
OCCUPANCY TYPE OF CONSTRUCTION STORIES
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ =
BUILDING SQ. FT. @ =
• BUILDING SQ. FT. @ –
TOTAL SQ. FT. TOTAL VALUATION
BUILDING PERMIT NO. PLAN CHECK FEE RECD RECEIPT NUMBER
PERMIT FEE PLAN CHECK FEE PLUMBING FEE MECH. FEE
TOTAL FEES WSBCC SURCHARGE ENERGY SURCHARGE
OTHER CHARGES I AMOUNT DUE
BUILDING DEPARTMENT APPROVAL BY
ASSIGNED ADDRESS
DATE
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