2012, 08-21 Permit App: EGR-2012-0026 GradingSpokane
Valley��
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 720-5240
Fax: (509) 688-0037
oermitcenter spokanevallev.orq
(Staff Use Only)
PERMIT No.:
CHECKLIST?: Dv ❑N INIT:
LAND DISTURBANCE PERMIT APPLICATION
1
STAFF USE :
❑ ENGINEERED GRADING
El REGULAR GRADING 0 GRUBBING & CLEARING
APPLICANT USE
SITE ADDRESS:
ASSESSORS PARCEL NO.: 4631-4,0103 ? 46 34-4, 4c) (
APPLICANT NAME: L !J L N o (1A $
PHONE: 9L4 ^-'Z.. t
EMAIL: k 4of17ert LIJ L1\OAjeS ,cpnetCELL: 2 1 -1 - 1 US Z
CONTACT NAME (® SAME AS APPLICANT):
PHONE: EMAIL:
CELL:
PROPERTY OWNER NAME: LN w 140 ej
MAILING ADDRESS: 2.10 etWe S 14./ A.\)c So( 4.e. Sob
CIN: S?ok one va 1 Le/ STATE: kAJ A
PHONE: '3 14 "(Z (
,L9 CHECK IF APPLICANT
EMAIL: kiirpe &. (n t kf1o, es .Conn
zip: 99ZOE;
CELL: 211— 105 2_
....rn i rwa.1 um. rvAmt: (LJ I UU): 1.7-1 ler Coe ,
❑ CHECK IF APPLICANT
MAILING ADDRESS:
Project #.--,,,-0- ` ae :,..
'
CITY: STATE:
ZIP:
PHONE: EMAIL:
CELL: AUG 2 1 2012
STATE LIC. NO.: EXPIRES:
UBI:�CENTER
PERM!T
DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE:
SUB #
7
\_ , Y _.__
1n ase- 3 0$ R o+ti ,�c1cl, 41 0.4 w i I ( Cons iso o4' +tie elLeve 61, p te'l ac
�I- s 1 i e - u n1 I I Y 1 o- -s and - i ( S4-aeA t m Qro,,eMen - -Iv ,4v cc(an C4
1, 140 PIe%a.Se 2 .
which --les
ESTIMATED QUANTITIES (CUBIC YD): CUT:
600 FILL: 8 06
IF CUT, PROVIDE DESTINATION OF SOIL: To 4 0 n 4.14 e
(o4s
START DATE: S/Z o J Z ESTIMATED COMPLETION DATE: (( /zo I Z.
/ /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
11111
jVauey
LAND DISTURBANCE (LL:PERMIT CHECKLIST
For Grading, Clearing and Grubbing work outside the Right -of -Way (ROW)
(For work within ROW need a ROW permit)
Permit Center + 11703 E Sprague Ave Suite B-3 ♦ Spokane Valley WA 99206
509.688.0197 ♦ Fax: 509.688.0037 A permitcenter@spokanevalley.org
Project Address: SZ2e cyke..c,; Today's Date: 8/'Zi /
Project Description: F ase- 3 o4 Rcf i A,ccct t -tIUn (j4 I 031 Y i u *s)
Signature: ��----
<��-- Print Name: A.c{esc,n S, ",t?So z�
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.
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; 2 sets plans, calcs etc. from Engineer)
;ti Yes No Will this grading be for a short plat, subdivision or binding site plan?
Yes I j No Will any grading occur in a FEMA floodplain, wetland, wetland buffer, Fish and Wildlife
habitat conservation area or geologically hazardous area?
El Yes ❑ No Will the volume of excavation or fill for the project be over 500 cubic yards? (If checked Yes
then a SEPA environmental checklist will need to be submitted for review)
IX Yes I I No Will the grading create a base or support for a permanent structure?
❑ Yes - No Will the grading be for a driveway that is longer than 75 feet?
❑ Yes No Will any grading occur in a drainage channel or be for a water feature (like a perennial or
intermittent pond) with a surface area greater than 500 square feet?
Yes 1 I No Will this grading result in the addition or replacement (excluding pavement maintenance) of
5,000 square feet or more of impervious surfaces or the disturbance of 1 acre or more land
or the construction of new drywells or other underground injection control (UIC) facilities?
n Yes No Will any excavations or fills have slopes at 2:1 (H:V) or steeper and heights greater than 2 1/2
feet?
Yes 1 I 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; 1 set of plans showing grading and
temporary erosion and sediment control; does not require engineering)
Yes U No Will the volume of excavation or fill be over 50 cubic yards on any one lot?
Yes I>:I No Will any excavations have slopes at 2:1 (H:V) or steeper or heights greater than 3 feet?
❑ Yes LI No Will any fills have slopes at 2:1 (H:V) or steeper or heights greater than 2 feet?
PART 4 - Grubbing and Clearing (G&C) Permit needed? (SVMC 24.50.050; 1 set of plans showing G&C
and temporary erosion and sediment control; does not require engineering)
Yes I I No 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)
Yes N 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.
II
1I
I'1
11
1/1