2004, 06-30 Permit App: BLD-04-04816 ShopSpine.0000Valley
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: 12E03 C, leo-xu:e.11
Assessor's Tax Parcel Number(s): Y 61 Se -2. b30 t
Legal Description:
0
PERMIT DESCRIPTION: 7616 i'J'
g Building Permit ❑ Change in Use ❑ Grading
❑ Relocation 9 Tenant Improvement ❑ Fire Safety
9 Manufactured Home
9 Other
OWNER/APPLICANT INFORMATION
ill
Owner: e?..Or i- -S wl`, -e- S', A jrp 9 Applicant:
Phone: Rqi-L,ij7' Fax: Phone: Fax:
Address: 17''o3 C 040n ll Address:
Valley \O 9521 b
City _J State Zip Code City State Zip Code
9 Contractor:
Phone:
Address:
Fax:
9 Architect:
Phone: Fax:
Address:
City State Zip Code City
WA State Contractor License #:
Contact:
State Zip Code
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK do I
DIMENSIONS:.24 lx 301
# OF STORIES:
MAIN FLOOR TO SQ. FTG:, 2v
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:
iaoA t
# OF BEDROOMS:
TOTAL HABITABLE SPACE:
IMPERVIOUS SURFACE AREA:
COST OF PROJE
,' ti 7‘
(/t
30% SLOPES ON PROPERTY:
S A :lab' O - PTIC
SYSTEM?
MANUFACTURED HOME
Width:
Length: Year:
Manufacturer:
Pit Set:
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler: # of Heads: Fire Alarm:
Tent:
Valuation: Above/Underground Storage Tank Size*
Paint Booth:
Fireworks Display: Blasting: Date/Time:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
•Phone:
Fax:
City
Inspector: Phone:
Address:
State
Fax:
Zip
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING
❑ CONCRETE
❑ REINFORCEMENT
Firm Name: 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 Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash g Check ❑ Mastercard ❑ VISA ❑ Other
Bankcard #: n�) Expires: VIN#:
•
Authorized Signature:
�, �'1�U 1' E'LA.N
NAME on J,w„PSoA.
ADDRESS• I2i3.63 E. Mo swell
-Proper%
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, c urb inn, structures and easements -
have been idents{ed. Also indicated are wetlands,
bodies of water, slopes of Dawn critical areas.
Signed: Cr 7, ,
Date: 6 -3o oy
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PARCEL # /6(52 i� O� ROAD WIDTH.
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COMMENTS
REVIEWED B