2004, 02-04 Permit App: BLD-04-03504 Remodelsii flk e
Valley
PERMIT APPLICATION WORK SHEET
SPOKANE VALLEY COMMUNITY DEVELOPMENT
BUILDING DIVISION
11707 East Sprague Ave Ste 106
Spokane Valley, WA 99206
Phone: (509)688-0036 Fax: (509)688-0037
REQUIRED SITE INFORMATION
STREET ADDRESS: l� Arp,L%
an/P/V fir/
ASSESSOR'S TAX PARCEL NUMBER(S):
LEGAL DISCRIPTION:
PERMIT DESCRIPTION:
DIIILDINGPERMIT
®RELOCATION
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® CHANGE IN USE
SIGN
O GRADING
® TENANT
gt
O MANUFACTU D HOME
® OTHER
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OWNER / APPLICANT INFORMATION
® OWNER: ?f UP 42#/ if /s
PHONE: �FAX:
(pG
ADDRESS: P /Z L' /!/e.0 O/yfP0/ n-2/2-
CITY,STATE, ZIP
°CONTRACTOR:
PHONE:
ADDRESS:
CITY, STATE, ZIP
® APPLICANT: 521SP41 /t
AX:
PHONE: 56. % _ G 24
ADDRESS: //23 �1�6ad-
FAX: -2414- GS) -S2$ Z_
/a dt, r JE-?
CITY, STATE, ZIP
ARCHITECT: 41-20AIP
PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
WA ST CONTRACTOR LICENSE # SySPr/Sd 334)47 CONTACT:
PERMIT/BUILDING INFORMATION
COST OF PROJECT: � -700 en
BUILDING HEIGHT TO PEAK:
BUILDING DIMENSIONS:
NUMBER OF STORIES:
NUMBER of BEDROOMS:
FLANKING SETBACK:
FRONT SETBACK:
REAR SETBACK:
LEFT SETBACK:
30% SLOPES ON PROPERTY:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
STRUCTURES ON PROPERTY:
CRITICAL AREAS:
CURRENT PROPERTY SIZE:
CURRENT PROPERTY USE:
CURRENT SEPTIC USE:
CURRENT WELL USE:
RIGHT SETBACK: IMPERVIOUS SURFACE AREA:
MAIN FLOOR SQ FT:
2ND FLOOR SQ FT:
UNFIN BASEMENT:
FINISHED BASEMENT:
GARAGE: •
COVERED DECK:
DECK:
MANUFACTURED HOME
SIGN
WIDTH: LENGTH:
YEAR: PIT SET:
MANUFACTURER:
SQ FT OF SIGN: HEIGHT OF SIGN:
# OF SIGNS: AREA OF EXIST SIGN:
TYPE OF SIGN:
RELOCATION
FIRE SAFETY
PREVIOUS ADDRESS:
PROPOSED USE:
FIRE SPRINKLER: FIRE ALARM:
PAINT BOOTH:
FIREWORKS DISPLAY:
BLASTING:
TENT:
DATE/TIME:
WA STATE NON-RESIDENTIAL ENERGY CODE
PLANS EXAMINER: PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
INSPECTOR: PHONE: FAX:
ADDRESS:
CITY, STATE, ZIP
SPECIAL INSPECTIONS
® BOLTING
FIRM NAME:
INSPECTOR(S):
CICONCRETE
CI REINFORCEMENT
PHONE:
® WELDING
FAX:
BUILDING STAFF USE ONLY
IS PUBLIC SEWER AVAILABLE: CI YES 0 NO IF YES: ® COUNTY ® CITY
IS PUBLIC WATER AVAILABLE: 0 YES 0 NO IF YES, WHICH WATER DIST/IRR:
IS PROPERTY LOCATED WITHIN DESIGNATED STORMWATER CONTROL AREA: 0 YES 0 NO
IS THE PROPERTY LOCATED WITHIN ASA: 0 YES ® NO
PSSA: 0 YES Ef NO
METHOD OF PAYMENT.'
CASH CHECK
VISA
BANKCARD A' EXPIRES: VIN 4
AUTHORIZED SIGNATURE.'
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
Spokane
Valley
Mechanical Permit Application
11707 East Sprague Avenue, Suite 106 509-688-0036 - Phone
Spokane Valley, WA 99206 509-688-0037 - Fax
For Inspections, call 509-688-0054
PROJECT #
/
ADDRESS: 4 /? A- "O0�y�O1114l/
/V / /
PERMIT
USE:
OWNER'S _ Jp�f0 /1-47,4A,'
m A 5
PHONE (Daytime Contact):
MAILING ADDRESS:
COST
EQUALS
(street)
1
(city/state) (ZIT)
CONTRACPOR:3-41:5Po' /` , L 6;4
../e/04.05-
LICENSE#: �aid
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MAILING ADDRESS:
/y2 y0 /CAA1es/
/ it?71h11 M
/
PHONE 1:
805 Gzie
2
Z
/c i/&-S�
(street)
(city/state) (ZIP)
METHOD OF PA
❑ CASH ❑ C
DATE:
EXPIRES:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
DESCRIPTION OF WORK
4 OF UNITS
X
COST
EQUALS
AMOUNT
1
FUEL BURNING APPLIANCE
• OR<100,000
X
515
2
FUEL BURNING APPLIANCE
> 10R000
X
519
-
3
UNLISTED APPLIANCE (ADDITIONAL FEE)
• OR<400,000
X
550
4
UNLISTED APPLIANCE (ADDITIONAL FEE)
> 400,000
X
5100
5
USED APPLIANCE (WSEC min AFUE rating)
or <400,000
X
550
6
USED APPLIANCE (WSEC min. AFUE rating)
> 400,000
X
5100
-
7
BOILER/REFRIGERATION
1 - 100M BTU
X
515
B
BOILER/REFRIGERATION
101- 500M BTU
X
528
-
9
BOILER/REFRIGERATION
501- 1,000M BTU
X
539
•
10
BOILER/REFRIGERATION
1601- 1,750M BTU
X
557
=
11
BOILER/REFRIGERATION
+1750M BTU
X
595
-
12
GAS LOG, GAS INSERT, GAS FIREPLACE
-
X
510
13
RANGE
-
X
$10
=
14
DRYER
-
X
$10
-
15
FUEL BURNING WATER HEATER
--
X
510
-
16
MISC FUEL BURNING APPL.
-
X
510
-
17
GAS PIPING (ea Outlet)
-
X
51
-
18
DUCT SYSTEMS
X
510
•
19
VENTILATING FANS
-
+
l
X
510
20
AIR HANDLER (DOES NOT include ducting)
•OR < 10,000CFM
X
512
•
21
AIR HANDLER (DOES NOTinclude ducting)
>10,000CFM
X
519
22
EVAPORATIVE COOLERS
-
X
510
=
23
TYPE I HOOD
-
X
550
-
24
TYPE If HOOD
-
X
510
25
HEAT PUMP/AIR CONDITIONER
0-3 TON
X
512
•
26
AIRCONDMONER
3-15 TON
X
520
-
27
AIRCONDITIONER
15-30 TON
X
525
28
AIR CONDITIONER
30-50 TON
X
535
-
29
AIR CONDITIONER
+50 TON
X
560
-
30
LPG STORAGE TANK
-
X
510
31
WOOD OR PELLET STOVE/INSERT
-
X
S10
-
32
WOOD STOVE - FREESTANDING
-
X
525
,1ENT
VISAs 6-..
SUBTOTAL:
PLUS PROCESSING FEE:
$35.00
TOTAL PERMIT FEE DUE:
DATE:
EXPIRES:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
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