2003, 04-03 Permit App: BD-03-025 PoolCity Of
SPOKANE VALLEY
PERMIT #
BUILDING PERMIT APPLICATION
Box 1 OWNER L/l�> JOB LOCATION S lV„JAY* IC. -O"
OWNER'S ADDRESS CITY J&k±A&yyHONE Aq3.q 55,$
DESCRIBE JOB
THIS PROPERTY IS OWNED BY: SINGLE/MARRIED
PARTNERSHIP CORP.
BOX 2 CONTRACTOR'S NAME=�%Opti RDnN >LI,C. PHONE
CONTRACTOR'S ADDRESS �x b2 y CITY _0A(_agr,-L
CONTRACTOR'S REG.# R"LI ?L O quDS EXPIRATION DATE - O
(CARD MUST BE PRESENTED AND COPIED OR VERIFIED)
BOX 3 CONTACT PERSON OF PROJECT K -V ►Jkz� S�•O�t,J- (� PHONE
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ADDRESS k�> O)- 6v14 � CITY0.,1/l2 ZIP
BOX 4 SEWER AVAILABILITY
WATER AVAILABILITY
BOX 5 ESTIMATED PROJECT COST $ EXISTING BLDG. VALUATION $
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BOX 6 PROPERTY TAX ACCOUNT NUMBER
LEGAL DESCRIPTION
(IF NECESSARY, PLEASE SUBMIT A SEPARATE PAGE WITH THE LEGAL DESCRIPTION)
CENSUS NUMBER LOT NUMBER
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BOX 7 BUILDING SQUARE FOOTAGE (Existing/ proposed) 1ST FLOOR / 2ND FLOOR /
3RD FLOOR
BASEMENT UNFINISHED
OTHER
CARPORT / TOTAL
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BOX 8 ( ) SINGLE FAMILY
( ) MULTIFAMILY (NO. OF UNITS
( )
COMMERCIAL/ INDUSTRIAL
(
TENANT IMPROVEMENT
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BOX 9 PLUMBING FIXTURES (Including rough -ins)
BASEMENT FINISHED
DECK / GARAGE
HEIGHT TO PEAK OF BUILDING FT.
( ) NEW CONSTRUCTION
( ) EXISTING STRUCTURE
TOTAL AREA OF PROPERTY SQ. FT.
IMPERVIOUS SURFACE _ f� SQ. FT.
MECHANICAL APPLIANCES
PLEASE USE THE ATTACHED PLUMBING / MECHANICAL FORM FOR THE LISTING OF ALL APPLIANCES,
SYSTEMS, HEATING AND AIR UNITS, FIREPLACE INSERTS, WATER HEATERS, CONVERSION BURNERS,
LAWN SPRINKLER SYSTEMS, BACK FLOW PREVENTERS, ET AL.
BOX 10 Water Service meter size (if known) Also see BOX 4
BOX 11 Septic Tank - Not generally allowed in the City of Spokane Valley. For special circumstances contact
Your sewer purveyor and the Health District (See BOX 4)
BOX 12 Street use may require a " Street Use Permit" for sewer, water, sidewalks, curb cuts. Contact the Public
Works Department.
I VERIFY UNDER THE PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE
ABOVE PREMISESTO ERFORM THE WORK FOR WHICH THE APPLICATIgNISJMADE.
OWNER/ AGENT (WAlDATE J 3 (OVER)
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card:
Visa Mastercard _ _ _ — Expiration Date
Print the name of the Holder c!__ _
- OFFICE USE ONLY - PLEASE DO NOT WRITE BELOW THIS LINE
ZONE SETBACKS: FRONT SIDE REAR HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL DISAPPROVAL DATE
REMARKS
SEPA: EXEMPT NOT EXEMPT
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FIRE DEPARTMENT APPROVAL
REMARKS
DISAPPROVAL
PUBLIC WORKS DEPARTMENT APPROVAL DISAPPROVAL
DATE
DATE
TYPE OF JOB: NEW RESIDENCE RES. ADD/ALT NEW INDUSTRIAL IND. ADD/ALT
NEW COMMERCIAL COMM. ALT/ADD NEW MULTIFAMILY NO. UNITS
MULTIFAMILY ADD/ALT TENANT IMP. ROOF OTHER
OCCUPANCY TYPE OF CONSTRUCTION STORIES
BUILDING PERMIT NO.
PERMIT FEE
TOTALFEES
OTHER CHARGES
UILDING SQ. FT. @ _
BUILDING SQ. FT.
BUILDING SQ. FT.
BUILDING SQ. FT.
TOTAL SQ. FT.
a'7 =
TOTAL VALUATION
PLAN CHECK FEE RECD
RECEIPT NUMBER
PLAN CHECK FEE PLUMBING FEE MECH. FEE
WSBCC SURCHARGE ENERGY SURCHARGE
BUILDING DEPARTMENT APPROVAL
ASSIGNED ADDRESS
BY
AMOUNT DUE
DATE
10
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