2004, 06-30 Permit App: BLD-04-04831 ResidenceSicikane
�
,,,,,.:Malley
11707 E. Sprague Ave., Suite 106
Spokane Valley, WA 99206
Job Address: 919 S SHELLEY LAKE LN
SPOKANE VALLEY WA 99037
NEW RESIDENCE W/ATTACHED GARAGE - GAS
Description:
Subdivision:
Owner:
Applicant:
Address:
Contractor:
Address:
THIS IS NOT A PERMIT
Penalties will be assessed for
commencing work without a permit
NEW SINGLE FAMILY RESIDENTIAL
GEORGE H WHITE INC
GEORGE H WHITE INC
PO BOX 52
LIBERTY LAKE, WA 99019-0052
GEORGE H WHITE INC
PO BOX 52
LIBERTY LAKE WA 99019-0052
Application #: BLD -04-04831
Lot: Blk: Parcel No:
Phone: (509) 921-9752
Phone:
Lic No:
(509) 921-9752
GEORGHWO91 P8
Applied:
Issued:
Expires:
Zoning:
06/30/2004
01/08/2005
General Information:
TYPE OF RESIDENTIAL PERMIT
VALUATION
CLOTHES WASHER
GARBAGE DISPOSAL
FLOOR DRAINS
WATER USING DEVICE
FUEL BURNING APPL <= 100,000
GAS LOG, INSERT, FIREPLACE
DRYER
FUEL BURNING WATER HEATER
GAS PIPING (ea. OUTLET)
VENTILATING FANS
TYPE II HOOD
HEAT PUMP/AIR COND 0 - 3 TON
BUILDING HEIGHT TO PEAK
DIMENSIONS
# OF STORIES
# OF BEDROOMS
FRONT SETBACK
REAR SETBACK
LEFT SETBACK
RIGHT SETBACK
OCCUPANCY GROUP
CONSTRUCTION TYPE
STRUCTURES ON PROPERTY
CURRENT PROPERTY SIZE
CURRENT PROPERTY USE
SERVED BY SEPTIC SYSTEM
WELLS LOCATED ON PROPERTY
TOILETS
TUBS
SHOWERS (PER TRAP)
SINKS
DISHWASHER
sfr
163387
1
1
1
4
1
1
1
1
2
4
1
1
22
56 X 37
1
2
22
60
9
12
r-3
5-b
1
70 X 143
RESIDENCE
no
no
2
2
1
5
1
Fees:
PLAN CHECK FEE
TYPE II HOOD
GAS LOG, INSERT, FIREPLACE
DRYER
FUEL BURNING WATER HEATER
GAS PIPING
VENTILATING FANS
HEAT PUMP/AIR COND 0 - 3 TON
BASIC PERMIT FEE
WSBCC SURCHARGE
TOILETS
TUBS
SHOWERS
SINKS
DISHWASHER
CLOTHES WASHER
GARBAGE DISPOSAL
FLOOR DRAINS
WATER USING DEVICE
FUEL BURNING APPL <= 100,000
THIS IS NOT A RECEIPT
Total Calculated:
Deposits/Receipts:
Total Due:
540.86
10.00
10.00
10.00
10.00
2.00
40.00
12.00
1,352.15
4.50
12.00
12.00
6.00
30.00
6.00
6.00
6.00
6.00
24.00
15.00
2,114.51
0.00
CITY OF SPOKANE VALLEY
APPROVED FOR SUBMITTAL.
2,114.51
Planning /Z/C`i eZ�� r
Public Works / '' i.�---
CITY fIF
(Spokane
.,,,OMi ley
THIS IS NOT A PERMIT
Penalties will be assessed for
commencing work without a permit
NEW SINGLE FAMILY RESIDENTIAL
11707 E. Sprague Ave., Suite 106
Spokane Valley, WA 99206 Application #: BLD -04-04831
THIS IS NOT A RECEIPT
*awe
4000%lley
BUILDING PERMIT APPLICATION WORKSHEET
City of Spokane Valley Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
1 Phone: (509) 688-0036; Fax: (509) 688-0037
REQUIRED SITE INFORMATION
Street Address:
9/ 1 ��l�e� �rr�� Spm i)a-Ltey ki 97037
Legal Description: ( <J-1 e ii-dd i
PERMIT DESCRIPTION: aes �z- %� e �� r v -tfi 6511-1- 3 A `( L t fe #Qi c 4
Assessor's Tax Parcel Number(s):
5 Building Permit
Relocation
❑ Change in Use ❑ Grading ❑ Manufactured Home
❑ Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
. ❑ Owner: 6,e I'q ry )4
Phone: 71i 7>5-2_ Fax: '77 c :
Address: QQG
1 , b ,r t� � 1 41-.1e€._ v) . 990/
City State Zip Code
Contractor:
Phone:
vvv1 t'
Address:
Fax:
D
City
State
WA State Contractor License #: c' eorc"
Applicant:
Phone:
Address:
��i
City
❑ Archite
Pho
CC a WitOd
JUN 30 20(x'
#°Contact:
Fax:
•
F
Zip Code
V/,_, AV;
0
a in 11
State
PERMIT/B DING INFORMATION
Zip Code
HEIGHT TO PEAK
DIMENSIONS:
# OF STORIES:
MAIN FLOOR TO SQ. FTG: >/ ,/ T
2"1r FLOOR SQ. FTG: _____
UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG:
GARAGE SQ: FTG:
72-?
DECKICOV. PATIO. FTG:
/ L' X' z - /mac;
OCCUPANCY GROUP:,,.., •-•
'
CONSTRUCTION TYPE: 1
S- fl,,.'
HEAT SOURCE: r=0 ice 1)
4 k sr C, A
# OF BEDROOMS: ,7
TOTAL HABITABLE SPACE:/ / /,1
0'
IMPERVIOUS SURFACE AREA:
COST OF PROJECT: -30%
i 7 (J&
SLOPES ON PROPERTY:
(L) Cr)'le
SEWER OR9N-SITE SEPTIC
SYSTEM? Se- c-�(--2
MANUFACTURED HOME
Width:
Length: Year:
Manufacturer:
Pit Set:
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler: # of Heads: Fire Alarm: Paint Booth:
Tent: Fireworks Display: Blasting: Date/Time:
Valuation: Above/Underground Storage Tank Size:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
Phone:
Fax:
City State
Inspector: Phone: Fax:
Address:
Zip
City
State
Zip
SPECIAL INSPECTIONS
D BOLTING ❑ CONCRETE
Firm Name:
❑ REINFORCEMENT
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 in the property ow e
Print Name ' c "( i2 >L u Signature ( 4
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash r2Theck ❑ Mastercard
Bankcard #:
Authorized Signature:
0 .VISA
Expires:
❑ Other
VI N#:
•/\*.
,,Valley
Project Address: ':2/ ? S /7 el
Owner. (T ) %z h
Mailing Address:
Contractor. S Pry' rt E' -
Mailing Address:
MECHANICAL PERMIT APPLICATION
City of Spokane Valley Community Development Department
BuildingDivision
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone: (509) 688-0036; Fax: (509) 688-0037
FOR INSPECTIONS, CALL (509) 688-0054
Permit Use:1.,w/3
Phone (Daytime Contact): .22/ 7i_?-_
_ GC'
if-
City,State Zip de
License #: c7c- ' /] i Cc) c'Q9/f Phone #: 9'2/
i
METHOD OF PAYMENT:
0 CASH N CHECK 0 VISA ❑ MC
CARD #: ( \
AUTHORIZED SIGNATURE:
100,000
00
400,000
00
,000
00
U
rU
TU
BTU
0,000 CFM
10 CFM
ON
DATE:
EXPIRES:
City
# OF
UNITS
r
State Zip Code
)
/
X
X
X
X
X
x
x
X
X
X
X
X
x
x
X
X
x
X
X
x
X
X
X
x
X
X
X
X
X
X
X
X
X
COST
515.00
519.00
550.00
5100.00
550.00
5100.00
515.00
528.00
539.00
$57.00
595.00
510.00
510.00
510.00
510.00
$10.00
$1.00
3
510.00
510.00
512.00
519.00
510.00
550.00
510.00
512.00
520.00
SUBTOTAL
525.00
535.00
560.00
510.00
510.00
525.00
PROCESSING FEE
TOTAL PERMIT FEE DUE:
TOTAL.
AMOUNT
/a.
u
/0
/0`).°
535.00
-
535.00
_
DESCRIPTION OF WORK
Equal to or less than
1
FUEL BURNING APPLIANCE
More than 100,0
2
3
FUEL BURNING APPLIANCE
UNLISTED APPLIANCE (Additional Fee)
Equal to or less than ,
4
UNLISTED APPLIANCE (Additional Fee)
More than 400,0
USED APPLIANCE (WSEC min. AFUE
5
rating)
Equal to or less than
USED APPLIANCE (WSEC min. AFUE
6
rating)
More than 400.C
BTL
7
BOILER/REFRIGERATION
1 - 100M
BT
8
BOILER/REFRIGERATION
101 - 500M
B
9
BOILER/REFRIGERATION
501 -1,000M
1
10
BOILER/REFRIGERATION
1,001 - 1,750M
11
BOILER/REFRIGERATION
More than 1,750N
12
GAS LOG, GAS INSERT, GAS FIREPLACE
13
RANGE
14
DRYER
15
FUEL BURNING WATER HEATER
16
MISC. FUEL BURNING APPLIANCE
17
GAS PIPING (each outlet)
18
DUCT SYSTEMS
19
VENTILATING FANS
1
20
AIR HANDLER (DOES NOT include ducting)
Equal to or less than
10,01
21
AIR HANDLER (DOES NOT include ducting)
Greater than
22
EVAPORATIVE COOLERS
23
TYPE I HOOD
24
TYPE II HOOD
0-3 TON
25
HEAT PUMP/AIR CONDITIONER
3-15 TON
26
AIR CONDmONER
TOP
27
AIR CONDITIONER
15-30
30-50 TOP
28
AIR CONDITIONER
50
29
AIR CONDmONER
More than
30
LPG STORAGE TANK
31
WOOD OR PELLET STOVE/INSERT
32
WOOD STOVE - FREE STANDING
METHOD OF PAYMENT:
0 CASH N CHECK 0 VISA ❑ MC
CARD #: ( \
AUTHORIZED SIGNATURE:
100,000
00
400,000
00
,000
00
U
rU
TU
BTU
0,000 CFM
10 CFM
ON
DATE:
EXPIRES:
City
# OF
UNITS
r
State Zip Code
)
/
X
X
X
X
X
x
x
X
X
X
X
X
x
x
X
X
x
X
X
x
X
X
X
x
X
X
X
X
X
X
X
X
X
COST
515.00
519.00
550.00
5100.00
550.00
5100.00
515.00
528.00
539.00
$57.00
595.00
510.00
510.00
510.00
510.00
$10.00
$1.00
3
510.00
510.00
512.00
519.00
510.00
550.00
510.00
512.00
520.00
SUBTOTAL
525.00
535.00
560.00
510.00
510.00
525.00
PROCESSING FEE
TOTAL PERMIT FEE DUE:
TOTAL.
AMOUNT
/a.
u
/0
/0`).°
535.00
-
535.00
siiikane
PLUMBING PERMIT APPLICATION
City of Spokane Valley Community Development Department
BuildingDivision
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone: (509) 688-0036; Fax: (509) 688-0037
FOR INSPECTIONS, CALL (509) 688-0054
Project Address: 9/`1 S4cl/ett Permit Use: / s (-43 Cr/r 4-11-
Phone (Daytime Contact): 92/ ?75- Z
Owner:
Mailing Address: �(
City State Zip Code
Contractor. (, cJ \' V, (J L,4 -c- License #: k4 to Phone #: q2 / 975-2-
Mailing
75ZMailing Address: o,U. 6,)< -5 -2 --
bet,/ L.4(
t//5g
Lej
City State
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
Zip Code
DESCRIPTION OF WORK
SOF
UNITS
X
COST
=
TOTAL
AMOUNT
1
`
TOILETS
WATER CLOSET, BIDETS
Z
X
56.00
=
/Z-- ;
2
URINALS
X
$6.00
=
3
TUBS
Z.,
x
56.00
=
/2 ,
4
SHOWERS (PER TRAP)
BATH, STALL, ONSITE BUILT
J
X
$6.00
=
& ,
5
SINKS
LAVS/BASINS, BAR FLOOR
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD,
PREP/CULINARY/MEAT
X
$6.00
=
6
DISHWASHER
(
X
56.00
=
//
C%
7
CLOTHES WASHER
/
X
56.00
=
6 r
8
GARBAGE DISPOSAL
/
X
56.00
=
[O e-
9
9
WATER SOFTENER
X
56.00
=
10
ELECTRIC HOT WATER TANK
NOTE IF GAS, SEE MECHANICAL
X
56.00
=
11
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
/
X
56.00
=
„
12
ROOF DRAINS/OVERFLOW DRAINS
X
56.00
=
13
FOUNTAINS, DRINKING
X
56.00
=
14
WATER PIPING/DRAIN-IN WASTE,
VENT, PLUMBING, REVERSAL
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
X
56.00
=
15
SEWAGE EJECTOR
GRINDER, SUMP PUMP
X
56.00
=
16
WATER USING DEVICE
ICE AN/OR COFFEE MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLER
1 /
" 7
/
X
56.00
=
2
17
CROSS CONNECTION DEVICE
VACUUM BREAKER, CHECK
VALVE, AND R.P.B.P.D. FOR
VATS, TANKS, BOILERS
X
56.00
=
18
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
X
$6.00
=
19
MEDICAL GAS (per outlet)
NITROUS, OXYGEN
X
$6.00
=
20
MISCELLANEOUS PLUMBING FIXTURE
X
*6.00
=
METHOD OF PAYMENT:
0 CASH `,� CHECK 0 VISA 0 MASTERCARD
DATE I EXPIRES:
SUBTOTAL
/6 e v V
PROCESSING FEE
*35.00
TOTAL PERMIT FEE DUE:
/ ' f 3. ° `)
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
Zip Code
City. of
SPOKANE VALLEY
2001 WSEC.Residential Compliance Form
Prescriptive (Chapter 6) Options for all R Occupancies, Climate Zone 2 0; 1
Heat lource: ALL
BUILDING DEPARTMENT
11707 E. Sprauge Avenue, #106, Spokane Valley, Washington 99206 - Tel 509-921-1000 - Fax 509-921-1008
SITE ADDRESS:
PERMIT NO. DATE: 3 0 ; - 6'00 c
INSTRIJCTIONS
1) Your permit will be processed more efficiently if you provide all of the requested information. Department staff can
help you with general questions about this form. Your building must match the selected option requirements without
-exceptions or substitutions.
2) Glazing percentage determines which option to choose. Complete the following glazing area calculation before
proceeding to the option table below.
GLAZING AREA CALCULATION:
SF. — SF. =
TOTAL WINDOW AREA = HEATED FLOOR AREA (ALL FLOORS) =
% OF GLAZING
NOTE: Use rough opening (R/O) for window area. Include all half-Iite and full -lite door glazing in this
calculation.
%
CAN'T COMPLY? If none of the Prescriptive (Chapter 6) Options below are acceptable, consider systems analysis
(Chapter 4) or, Component Performance (Chapter 5) Approach. The main advantage is flexibility to juggle individual U -
factors (R -values) as long as an overall maximum value isn't exceeded. Note that the overall performance requirements
are no less stringent than the Prescriptive requirements. Calculations may be performed by hand or, using an acceptable
computer software program. Helpful forms and other resources can be downloaded at http://www.eriergy.wsu.edu/
buildings.
INSPECTORS COPY
MUST BE ATTACHED TO APPROVED PLANS
9
SKS Itc11'
0. Nominal R -values are for wood frame asserrbiies only or assemblies built in accordance with Section 601.1
1. Mninum requirements for each option listed. For example, if a proposed design has a glazing ratio to the conditioned floor area of 13%, it
shall only with all of the requirements of the 15% glazing option (or hider). Proposed designs, which cannot meet the specific
requirements of a listed option above, may calculate compliance by Chapters 4 or 5 of this Code.
2. Requirement applies to all ceilings except single rafter or joist -vaulted ceilings. 'Adv* denotes Advanced Framed Ceiling.
3. Requirement applicable only to single rafter or joist vaulted ceilings.
4. Below grade waifs shall be insulated either on the exterior to a minimum level of R -1Z or on the interior to the same level as wails above
grade. Exterior insulation installed on below grade walls shall be a water resistant material, manufactured for its intended use, and instated
according to the manufacturers specifications. See Section 602.2
5. Floors over crawl spaces or exposed to ambient air ca,d'tions.
6. Required slab perimeter insulations shall be a water resistant material, -manufactured for its intended use, and installed according to
manufacturers specifications. •
7. Int denotes standard framing 16 inches on center with headers insulated with a minimum or R-5 insulation.
8. This wall insulation requirement denotes R-19 wall cavity insulation plus R-5 foam sheathing.
9. Doors, including all fire doors, shall be assigned default U -factors from Table 10-6C.
10. Where a maximum glazing area is listed, the total glazing area (combined vertical plus overhead) as a percent of gross conditioned floor area
shall be less than or equal to that value. Overhead glazing with U -factor of L=4.40 or less is not included in glazing area limitations.
11. Overhead glazing shall have U.tactors determined in,aca rdance, with NFRC 100 or as specified in Section 5021.5.
12. Log and solid timber walls with a minimum average thickness or 3.5- are exempt form this insulation requireiren L
Form 5-050801-200tiResidential Comp Form
Option
Glazi n9
w
Areal':
Area : % of
Floor
Glazing U-Factorf
Door a
U -factor
Ceiling
2
Voluted
Ceiling'
Wall
Above
Grade
Wall' int a
Below
Grade
Wail'
ext
Below
Grade
Door ,
Slab'on
Grade
Vertical
Overhead"
I.
10%
0.40
0.58
0.20
R-38
R-30
R -t7
R-21
R-12
. R-30
R-10
❑
If.'
15%
0.40
0.58
0.20
R-38
R-30
R-19+
R -5°R-21
R-12
R-30
RAO
❑
Ill.
17%
0.37
0.58
0.20
R-38
R-30
R-19 +.
R-56
R-21
R-12
R-30
RAO
❑
iv.
Unlimited
a
0.35
0.58
0.20
R-38
R-30
rnf�1
R-21
R-/2
R-30
RAOOnly
0. Nominal R -values are for wood frame asserrbiies only or assemblies built in accordance with Section 601.1
1. Mninum requirements for each option listed. For example, if a proposed design has a glazing ratio to the conditioned floor area of 13%, it
shall only with all of the requirements of the 15% glazing option (or hider). Proposed designs, which cannot meet the specific
requirements of a listed option above, may calculate compliance by Chapters 4 or 5 of this Code.
2. Requirement applies to all ceilings except single rafter or joist -vaulted ceilings. 'Adv* denotes Advanced Framed Ceiling.
3. Requirement applicable only to single rafter or joist vaulted ceilings.
4. Below grade waifs shall be insulated either on the exterior to a minimum level of R -1Z or on the interior to the same level as wails above
grade. Exterior insulation installed on below grade walls shall be a water resistant material, manufactured for its intended use, and instated
according to the manufacturers specifications. See Section 602.2
5. Floors over crawl spaces or exposed to ambient air ca,d'tions.
6. Required slab perimeter insulations shall be a water resistant material, -manufactured for its intended use, and installed according to
manufacturers specifications. •
7. Int denotes standard framing 16 inches on center with headers insulated with a minimum or R-5 insulation.
8. This wall insulation requirement denotes R-19 wall cavity insulation plus R-5 foam sheathing.
9. Doors, including all fire doors, shall be assigned default U -factors from Table 10-6C.
10. Where a maximum glazing area is listed, the total glazing area (combined vertical plus overhead) as a percent of gross conditioned floor area
shall be less than or equal to that value. Overhead glazing with U -factor of L=4.40 or less is not included in glazing area limitations.
11. Overhead glazing shall have U.tactors determined in,aca rdance, with NFRC 100 or as specified in Section 5021.5.
12. Log and solid timber walls with a minimum average thickness or 3.5- are exempt form this insulation requireiren L
Form 5-050801-200tiResidential Comp Form
2001
WASHINGTON STATE ENERGY CODE UPDATE
This brochure is provided to assist in deciphering some of the Energy Code updates, and focuses primarily on
RESIDENTIAL changes of significance. This notice does not contain all of the changes occurring in the 2001 WSEC.
• Chapter 6, Prescriptive Requirements Approach — The code is now fuel -blind. Two tables (6-1, 6-2) replace six
previous tables. Table 6-2 is applicable in Climate Zone II, Eastern Washington.
■ Table 6-2 offers four options to achieve compliance based on the percentage of glazing in the home. Two
options (I, IV) require wall insulation values of R-21, the remaining two options (2I, III) require R-19 -f- R-5
foam sheathing. There are no substitutions permitted for the foam -sheathing requirement in. Options II, III.
*Hint: If your home design falls within the parameters of Options II or III, you may select option IV thus
permitting unlimited glazing area with U -factors of 0.35 or better. The benefit: you may then use the R-21
batts for wall insulation.
• Glazing U -factors of 0.40 are the minimum efficiency requirements for windows, and some instances may
require U -factors of 0.35.
• Minimum door U -factors are 0.20.
• Options I and IV require headers to be insulated to R-5 minimum.
• Ceiling insulation R -values have not changed.
• Compliance through Chapters 4 and 5 (heat loss calculations) may still be used, however, the Wattsun
program is being phased out. A new spreadsheet will be available soon through the WSU Energy Extension
Program and will be available on-line at: www.energy.wsu.edu/buildings/. In the mean time, if you use the
Wattsun software it must be version 5.7 for acceptance. Note: It will be increasingly difficult to show
compliance with un -insulated basement walls.
REMINDER — VIAQ/WSEC REQUIREMENTS
:ompliance has been off the mark in the following areas of the Ventilation & Indoor Air Quality Code/Energy
;odes since they became effective July 1, 2001.
• Labels must be provided on the whole house ventilation controls (e.g.; 24 hour timer), which read: "Whole
House Ventilation (see operating instructions)." Instructions must also be provided for the homeowner
describing the Whole House Ventilation System's operation.
• HVAC ductwork/furnace cabinets outside the conditioned space (attic, crawl space, garage) or stud bays, joist
cavities/spaces used to transport air must be sealed with welds, gaskets, mastics or mastic -plus -embedded -fabric
systems. UL 181A tape is permitted for rigid glass ducts, and UL 181B tape is permitted for flexible ducts.
Common duct tape is not permitted unless: the HVAC equipment (air handler in the case of heat pumps) and
ductwork are located entirely within the conditioned space.
0 N LY ONE FORM!
ttached is the new Washington State Energy Code Compliance Form containing Table 6-2, which reflects the
)coming insulation values. This form must be used if you choose to comply by the prescriptive approach (no
lculations necessary). This must be completed prior to receiving your permit.
Pr questions and information regarding these changes please contact our office at: 477-3675, or visit Washington State
iiversity Energy Extension Program web site: www.energy.wsu.edu/buildings/ .
UTILITIES DIVISION
N. Bruce Rawls, P.E., Utilities Director
A DIVISION OF THE
GENERAL FACILITIES CHARGE ( C)
PAYMENT OPTION SELECTION RECORD
PLEASE NOTE: Form must be filled out accurately and in its entirety, and signed, or a p
Date: 30 "SCR. N 0 �J
Plat Name: S iet e >< 2 y L ll-kto 7 `Ci Cid Lot No(s): 1-0T 8 Block No(s):
Site Address(es): / l �/ �i e. 1 L r{Lte Parcel No(s): 4h—g414-/.
Owner Name: 676-c= v'ejtk. VOL St 3. fl'C- OR Builder Name: > 4 k7 €_—
PRINT
PRINT Owners Name PRINT Builder's Name
IC WORKS DEPARTMENT
Payment Option Selected (Check One):
1. ❑ GFC payment received at issuance of Sewer Connection Permit by
Division of Utilities
2. GFC to be paid
Jat1closin. See Special
Conditions below regarding GFC rate.
e. �.J
3. ❑ GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
See Special Conditions below regarding GFC rate.
If Option No. 3 is selected, complete one of the following statements:
a. Owner's Statement: I, , understand that I will be
billed for the applicable GFC amount in 24 monthly installments. The monthly GFC installments will be added
to my monthly sewer service charges.
b. Builder's Statement: I, understand that because I
am selecting this option for payment of the GFC, the purchaser of the home will be responsible for payment of
the applicable GFC in 24 equal monthly installments. I agree to formally disclose to potential buyers of the
property that the GFC charges will be added to the monthly sewer service billings as soon as billing
commences.
Special Conditions: Sewer connection permits are valid for 12 months from date of issue. If final connection is
not completed and inspected within the 12 -month life of the permit, a new permit will be required and the GFC rate
that is in effect when the new permit is issued will apply.
Other Special Conditions: ❑ No
❑
— See Reverse Side of Form
Owner's or is Signature
r
3 6) 3/
- Date
Located at: 1026 W. Broadway, 4thFloornt Option Form, Revised 02-04-04
Spokane County, Division of Utilities.6 W. Broadway • Spokane, WA 99260 iR 0
(-nc» 4.77-.w4 • FAX: (509) 477-4715 • TDD: (509) 477-7133
SPOT NE Cowry
SPOKANE COUNTY
DEPARTMENT OF BUILDING & PLANNING
1026 WEST BROADWAY AVENUE • SPOKANE, WA 99260-0050
Site Information
Project Information
Site Address: 919 S SHELLEY LAKE LN
Parcel Number: 45244.3206
Subdivision:
Block: Lot:
Zoning: UNK Unknown
Owner: GEORGE H WHITE INC
Address: PO BOX 52
LIBERTY LAKE WA 99019
Building Inspector: BOBBY STONE
Water Dist:
Project Number: 04004680 Inv: 1 Issue Date: 7/1/2004
Permit Use: SEWER CONNECTION - SHELLEY LAKE 4TH
Applicant: GEORGE H WHITE INC
PO BOX 52
LIBERTY LAKE WA 99019 Phone: (509) 921-9752
Contact: GEORGE H WHITE INC
PO BOX 52
LIBERTY LAKE WA 99019 Phone: (509) 921-9752
Setbacks - Front: Left: Right: Rear:
GroupTlame:
Project Name:
Pr(
Permits
Sewer Connection Permit
Contractor: GEORGE H WHITE CONST License #: GEORGHWO91P8
SEWER CONNECTION 1 $85.00 PROCESSING FEE 1 $15.00
Total Permit Fee: $100.00
FOR SEWER INSPECTIONS CALL (509) 477-3604 UTILITIES 8:30-5:00 PM MONDAY THRU FRIDAY
Call for inspection prior to cover. ONE WORKING DAY NOTICE REQUIRED.
Contractor or applicant is to field locate and confirm the elevation and position of sewer stub prior to any other excavation.
Sewer stubs are to be checked prior to connection to ensure that they have acceptable grade and are clear and unobstructed to the main
sewer. Sewer lines should be constructed to allow for gravity flow from the lowest level of the structure.
This permit must be presented to the job site inspector for verification. To locate buried cables, gas piping, water lines, etc.
CALL BEFORE YOU DIG, (509)456-8000.
STATE LAW RCW 19.122 REQUIRES THAT PRIOR TO ANY EXCAVATION THE "CALL BEFORE YOU DIG" CENTER BE
NOTIFIED. CALL BEFORE YOU DIG AT LEAST 2 WORKING DAYS IN ADVANCE, (509)456-8000.
Spokane County Code requires the installer comply with all requirements of the Washington State Dept of Labor and Industries,
including those related to trench safety.
Payment Summary
Total Fees AmountPaid AmountOwing
$100.00 $100.00 $0.00
Tran Date Receipt # Payment Amt
7/1/2004 3573 $100.00
Processed By: SHATTO, JULIE
Printed By: WENDEL, GLORIA Page 1 of 1
%,, nn
Th
PERMIT
Shy tle�� L\�. t_ tor,.,
._. ___ <<_4 3 (' `tt cl'Ar- ---
G e,1- c, At,
T sILO
T��
submitted for the purpose of
obtaining
niM b b� s a true and correct
reprerepresentation 01
obtaining a builknown property
the permit
proproposal.MI and id efferents
lines/dimensions, curb lines, structures
s
have been identified. Also I n i nre nds'
critical areas.
bodies of water, steep slopes
Signed:
Date:
ADDRESS
ZONE
ROAD WIDTH 3
FRONT_--._ F
COMMENTS I
REVIEWED
i n • n.> -nen
i100^011 1 IAryTTAA .Aa lIIAQ