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2011, 04-05 Permit App: Land Disturbance
Sine -Vaileyx LAND DISTURBANCE PERMIT APPLICATION Community Development Department Permit Center 11703 East Sprague Avenue, Suite B-3 Spokane Valley, WA 99206 Tel: (509) 720-5240 Fax: (509) 688-0037 permitcenterCnlspokanevalley.org (Staff Use Only) PERMIT No.: CHECKLIST?: ❑Y ❑N INIT: STAFF USE: ❑ ENGINEERED GRADING ❑ REGULAR GRADING ❑ GRUBBING & CLEARING APPLICANT USE SITE ADDRESS: 11117 E. M/171.1 ASSESSORS PARCEL NO.: APPLICANT NAME: (4-,_1620P/ 84 -u - PHONE: [ /:— 7Z 03 EMAIL: CA -Mt C hp Aotntct C3Snv\. CELL: sAr-tG CONTACT NAME (® SAME AS APPLICANT): PHONE: EMAIL: CELL: PROPERTY OWNER NAME: ,V4T(4 E,4 LL- 0 CHECK IF APPLICANT MAILING ADDRESS' / S 03 S- St -4 K -E CITY: SP0KRI✓E VEILLEy STATE: WA ZIP: 95037 PHONE: EMAIL: CELL: CONTRACTOR NAME: (❑ TBD): 0 CHECK IF APPLICANT MAILING ADDRESS: CITY: STATE: ZIP: PHONE: EMAIL: CELL: STATE LIC. NO.: EXPIRES: UBI: DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE: ESTIMATED QUANTITIES (CUBIC YD): CUT: FILL: IF CUT, PROVIDE DESTINATION OF SOIL: START DATE: ESTIMATED COMPLETION DATE: / /20 Updated March 2011 \\SV-FS2\Public Folders\Community Development\02 Administration\03 Forms - Official Versions\Permit Center\Land Disturbance Permit & Checklist 3- 29-11.doc /1\i, sj�� LAND DISTURBANCE (LD) PERMIT CHECKLIST Permit Center ♦ 11703 E Sprague Ave Suite 8-3 • Spokane Valley WA 99206 509.688.0197 ♦ Fax: 509.688.0037 ♦ permitcenter®spokanevalley.org Project Addres7 Project Des Signature: IAbE F,2o r" T 57D7 Print Name: Today's Date: The purpose of this checklist is to gather information about the proposed project so to determine what land disturbance permit, if any, is required by the Spokane Valley Municipal Code (SVMC). Starting with Part 1 and working from top to bottom, please answer the following questions. The first "Yes" identifies the type of land disturbance (LD) permit required. PART 1 — Is LD work exempted or already covered? (SVMC 24.50.020) If so then LD permit not needed. ❑ Yes No Does your project only have to do with emergency utility work; cemetery graves; eliminating septic tanks; digging out a basement; building a wall Tess than 4 feet high; disposal of refuse that is covered under other regulations; already permitted mining, quarrying, stockpiling of aggregate material (rock, sand, gravel, aggregate, or clay) or exploratory excavations done under the direction of a licensed engineer or engineering geologists? If yes, then project exempted from a LD permit. PART 2 — Engineered Grading Permit needed? (SVMC 24.50.030) Yes EJ No Will this grading be for a short plat, subdivision or binding site plan? n Yes E No Will any grading occur in a FEMA floodplain, wetland, wetland buffer, Fish and Wildlife habitat conservation area or geologically hazardous area? ❑ Yes No Will the volume of excavation or fill for the project be over 500 cubic yards? ❑ Yes 0 No Will the grading create a base or support for a permanent structure? ❑ Yes [x' No Will the grading be for a driveway that is longer than 75 feet? ❑ Yes El No Will any grading occur in a drainage channel or be for a water feature (like a pond) with a surface area greater than 500 square feet? ❑ Yes © No Will any excavations or fills have slopes at 2:1 (H:V) or steeper and heights greater than 2 1/2 feet? U Yes No Will any excavations or fills have slopes at 10:1 (H:V) or steeper and heights greater than 4 feet? PART 3 — Regular Grading Permit needed? (SVMC 24.50.040) Yes 0 No Will the volume of excavation or fill be over 50 cubic yards on any one lot? Yes No Will any excavations have slopes at 2:1 (H:V) or steeper or heights greater than 3 feet? ❑ Yes 0 No Will any fills have slopes at 2:1 (H:V) or steeper or heights greater than 2 feet? 11 PART 4 —Grubbing and Clearing (G&C) Permit needed? (SVMC 24.50.050) Yes F,1 No ❑ Yes F Will the G&C work disturb 5,000 or more square feet of area or remove 7 or more trees? (Note that forest practices overseen by DNR or commercial agriculture are exempt) No Will there be any clearing on slopes or near/in FEMA floodplains, wetlands, wetland buffers, Fish and Wildlife habitat conservation areas, geologically hazardous areas or erodible soils? If the answers to all of the questions above are "No" then a permit is not required for the proposed work. Updated March 2011 11SV-FS21Public Folders1Community Development102 Administration103 Forms - Official Versions\Permit CenterlLand Disturbance Permit & Checklist 3- 29-11.doc