2004, 09-17 Permit App: BLD-04-07680 Reroof =p€ • : BUILDING PERMIT APPLICATION WORKSHEET.
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City of Spokane Valley Community Development Department
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Building Division
VaI 1170 .7 E. SpragueAvenue, Suite 106
e Spokane. Valley,y, l/VA 99206
• Phone: (503) 688-0036;Fax: (509) 688-0037
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REQUIRED SITE INFORMATION'-• -
Street Address: •• z ? /Z • 1'7 /I-,0/( . ige1, • - -
Assessor's Tax Parcel Number(s): . • .
Legal Description:
\ P.ERMIDESCRIPTION: r e roof ou)Q 50 c45. 6,4-- i,,,, �a 4-5ti.\(jfl/ (0/1(4A - P•')
-Building Permit . 0 Change in Use Grading
• ❑ Relocation0 Tenant Improvement ❑ Fire SafetyManufactured Home
. D Other
ft OWNER/APPLICANT INFORMATION y
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Owner: T3 ,r 12 31-(4144q v . 0 Applicant:
Phone:W.:7-73w Fax: Phone: Fax:
Address: (.2 7/2 S'S IAP// "-WI. Address:
. 5 d ect-- (i 7/, L42de
Ci stateti� •
City ,State Zip Code
❑ Contractor: ••
• Phone: �• �❑ Architect: •
Fax: Phone: Fax:
Address: •
Address:
City State Zip Code • City. • State
Zip Code
WA State Contractor License#: Contact;
I - • ..• PERMIT/BUILDING •
INFO X
R.I1fIA�`IO.N
HEIGHT TO PEAK • ' DiMEMSIONS:
#OF STORIES:,
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MAIN FLOOR TO SO: FTG: -` u:FLOOR SQ.-FIG:
• =-- UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG: GARAGE SQ FIG:
• : DECK/COV. PATIO SQ. FTG:
OCCUPANCY GROUP: CONSTRUCTION TYPE:
• HEAT SOURCE:
#OF BEDROOMS: TOTAL HABITABLE SPACE IMPERVIOUS SURFACE AREA:
COST OF PROJECT: • 30%SLOPES ON PROPERTY: SEWER OR ON-SITE SEPTIC
42-/ rl e)0 x 6 0 SYSTEM?
. MANUFACTURED HOME .
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Width; • Length: Year:• Pit Set: • •
Manufacturer: • .
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• • ' RELOCATION •• - . •
. : Previous Address: . . .
Proposed Use:
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FIRE SAFETY •
• Fire Sprinkler: # of Heads: Fire Alarm: Paint.Booth:.
Tent: - Fireworks Display: Blasting: •• . . Datelme:
Valuation: • Above/Underground Storage Tank Size: .
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE •
Plans Examiner: Phone: . Fax:
Address: - ••
City State Zip.
Inspector: Phone: . Fax:
Address:
- City State . Zip
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f s SPECIAL INSPECTIONS I
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❑ BOLTING •
❑ CONCRETE • 0 REINFORCEMENT 0 WELDING
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Firm Name: . . Phone:. Fax:
Inspector(s): •
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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:Spbkane Valley
Permit is not a permit or approval-for any violation of federal, state or local laws, codes or ordinances. "
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Ownership of resulting development rights granted by any issued permit inure to the property owner.
Print Name • Signature
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. Method of Payment: (Faxed permit applications will only be accepted with major bankcard).
D Cash ❑. Check . ❑ Mastercard . • 0 VISA • 0 Other
• Bankcard#: Expires: • - .VIN#:
Authorized Signature: •