2005, 10-27 Permit App: 05004052 ReroofUU l . D ZKJbJ Cl KJ ri I
-4-3S BUILDING PERMIT APPLICATION WORKSHEET
Cityof Spokane Valley Community Development Department
Stiorkane
Building Division
11707 E400,V. Sprague Avenue, Suite 106
aIle Spokane Valley, WA 99206
Phone: (509) 688-0036; Fax: (509) 688-0037
REQUIRED SITE INFORMATION
Street Address: / 3 \ O (p E. J' -i LLQ
Assessor's Tax Parcel Number(s):
Legal Description: Qn /
PERMIT DESCRIPTION: /Q� /C\2 c6� �d.Ps/// / 7 pJj� 4; € '
7
3 Building Permit ❑ Change in Use Grading ❑ Manufactured Home
❑ Relocation 0 Tenant Improvement 0 Fire Safety ❑ Other
f
OWNER/APPLICANT INFORMATION
❑ Owner. ()Arc 5+1#U40-, ; I
Phone: Raz- 33 y 7 Fax:
Address: i 310 C E p1 Au u Cr"
o k-roae tia 1 ! Wei 942./
CI State Zip Code
❑ Applicant:
Phone:
Address:
Fax:
City
State Zip Code
® Contractor: PSTOU EJ C0k/Sne te-77 A/CO iIe-❑ Architect:
Phone: /b 8-'1981 Fax: /746:--c7-68"/ Phone: Fax:
Address: ,p,03S1S Address:
N, Me H� t o i`a. //J t.[1,4 9 40 2
City State Zip Code City
State Zip Code
WA State Contractor License #: CAP57-CL. f O0 -S Contact: AN ky -o h NS ' &4' /5a5
Spokane Valley Bus. Liscense #:7/TS Contact:
Laile•Mia=camp
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:
't# OF BEDROOMS:
TOTAL HABITABLE SPACE:
IMPERVIOUS SURFACE AREA:
COST OF PROJECT: ✓
�`�/00
30% SLOPES ON PROPERTY:
SEWERSYSTEM?R ON-SITE SEPTIC
OCT 25 2005 08:48
PAGE.01
OCT -25-2005 09:31 AM Capstone
MANUFACTURED HOME
Width:
Manufacturer:
Length: Year: Pit Set:
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler:
Tent:
Valuation:
# of Heads: Fire Alarm:
Paint Booth:
Fireworks Display: Blasting: DaterTime:
Above/Underground Storage Tank Size:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
Phone: Fax:
Inspector:
Address:
City
Phone:
State
Zip
Fax:
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING E CONCRETE
Firm Name:
inspector(s):
E REINFORCEMENT
Phone:
WELDING
Fax:
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 $ e property ow
io:
Print Name -SX Si-MCA/LOA/
Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
0 Cash
Bankcard
Mastercard
iz VISA
❑ Other
►spires: VIN#:
Authorized Signature:
OCT 25 2005 08:49
This document originally contained
confidential credit card information which
was redacted pursuant to RCW 19.255.010
and the original document destroyed
pursuant to SOS DAN GS2014-030.
PAGE.02