2004, 06-03 Permit App: BLD-04-04486 Pole Bldg pane
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PERMIT APPLICATION WORK SHEET
SPOKANE VALLEY COMMUNITY DEVELOPMENT
BUILDING DIV/S/ON
11707 East Sprague Ave Ste 106
Spokane Valley, WA.99206. ...
Phone:(509)688-0036 Fax:(509)688-0037
REQUIRED SITE INFORMATION
STREET ADDRESS: /- Lc+ S O+C 5 , j 1 1 7 54e e yt Co tio4
ASSESSOR'S TAX PARCEL NUMBER(SI: y5.2 yy./OOI
LEGAL DISCRIPTION:
PERMIT DESCRIPTION: . 5-0•3C'eicr
7 DING P RMTI" 0-C$ANGE IN USE JO GRADING a MANUFACTURED HOME
0-RELOCATION. ®-SIGN ®-TENANT 0-OTHER
OWNER / APPLICANT INFORMATION
® OWNER: h Ft5� f ® APPLICANT:
eitx
S- 4'390 CA)4.
PHONE: S9?^ 93bG Non FAX: PHONE: FAX:
ADDRESS: 1 } k ? �4 a e„t (� . ADDRESS:
Sok&Ke Vcl1 eJ. �,,J n- 4903? CITY,STATE,ZIP
-
CITY,STATE,ZIP
®CONTRACTOR:To cc '►-- Gov 114-7r . 81.4;4a.gfs ® ARCHITECT:
PHONE: 5-35--90{in FAX: 5-3 tit- Z b(3 6 PHONE: FAX:
ADDRESS: 5-1/cc- E Tv 64,4". ADDRESS:
poken e rAJk qq�Z 1 Z__ CITY,.STATE,ZIP
"CITY,STATE,ZIP
ACTOR UCENSE# TO W W "CLI/ f 23 G ` CONTACT:
PERMIT/BUILDING INFORMATION
COST OF PROJECT: - 30%SLOPES ON PROPERTY: MAIN FLOOR SQ FT: 2 900
BUILDING HEIGHT TO PEAK: aCCUPANCY GROUP: 2ND FLOOR SQ FT:- %0 O
BUILDING DIMENSIONS: CO Yi CONSTRUCTION TYPE: UNFIN BASEMENT:
NUMBER OF STORIES: rx STRUCTURES ON PROPERTY: FINISHEDBASEMENT:
NUMBER of BEDROOMS: RI CRITICAL AREAS: GARAGE: __
FLANKING SETBACK:
CURRENT PROPERTY SIZE: COVERED DECK:
•
FRONT SETBACK: )�'f 2-. F — CURRENT PROPERTY USE: DECK:
REAR SETBACK: 5-40 + CURRENT SEPTIC USE:
LEFT SETBACK: oZ '4"- CURRENT WELL USE:
RIGHT SETBACK: l�O IMPERVIOUS SURFACE AREA:
Call 24 hours before inspection required
.01"\thk Phone 509.688-0195 Fax Wane
.00"alley
DEPARTMENT OF PUBLIC WORKS
Anticipated start date Permit# R611) — J 014
ROW CONSTRUCTION PERMIT
Location of property 1\ -'? A . lJ� '
�y�`� .(Address/ rcel#, if available)
App ican am ` Fax
Address Phone
Contractor's Name
Address Phone
Contractor's Reg.# Expires
PROJECT DESCRIPTION (Provide site sk ch or Ian as necessary for clarity)
Sewer Connection Driveway
Curb &Gutter ri Gas Installation/Repair
Cable/Conduit/Pole ❑ Sidewalk Repair/Construction
El Water Installation/Repair n Other •
Pavement Cut Dimensions
Bond/insurance certification must be on file with the City.Bond#_
SPECIAL CONDITIONS:
Q COATCLI/U)1)C\i0XfOithei-UhUO)
Permittee Signature - Approved Date
I hereby authorize the City of Spokane Valley to charg he fee for this permit to my credit card.
Card# Expiration Date
Name of Holder Signature
Fees Paid$ AS%Di) -S, 0 U Date /019) 01( Init
(Application) (Inspection)
In addition to the permit application fee of$16.00(utility)or$25.00(construction), inspection on
each permit will be billed to the permittee at a rate of$50.00 per hour with a$25.00(1/2 hour)
minimum. Permittee signature constitutes an agreement to these terms and provisions.
Work completed satisfactorily(Signed) Date
poQ
Permit not valid until One-Call Notification Ticket#entered here IP -
PERMIT MUST BE KEPT ON SITE
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PLANNMtM DEPT.APPROVED
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DATE: , 3 • ��,
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ADDRESS - ► . ..la.
ZONE '
ROAD MOTH /
FRONT fl FLANKING
COMMENTS i
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