2005, 05-18 Permit App: 05001679 Change of Use '" �we. ..� BUILDING PERMIT APPLICATION WORKSHEET
cr1 - City of Spokane Valley Community Development Department
-,, Building Division
11707 E. Sprague Avenue, Suite 106
4000Vale Spokane Valley, WA 99206
.17 Phone: (509) 688-0036; Fax: (509) 688-0037
REQUIRED SITE INFORMATION ' /09
Street Address: / 6/ck /2 - 99c)//00 -
Assessor's Tax Parcel Number(s):
Legal Description: it49 -""Phi -4/ ,
PERMIT DESCRIPTION: / .�'� -f , fr4ftz
❑ Building Permit a Change I Use ❑ Grading ❑ Manufactured Home
❑ Relocation Tenant Improvement 0 Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
❑ Owner. ' 42
0 Applicant: •
Phone: 'a ;WA sr4,'ax: Phone: Fax:
Address: // Address:
C� ��� ,O - 3.
City tate Zip Code City State Zip Code
❑ Contractor: ❑ Architect:
Phone: Fax: Phone: Fax:
Address: Address:
City State Zip Code City State Zip Code
• WA State Contractor License#: Contact:
Spokane Valley Bus. Liscense #: Contact:
PERMIT/BUILDING INFORMATION 1
HEIGHT TO PEAK: DIMENSIONS: #OF STORIES:
MAIN FLOOR TO SQ.FTG: 2"D FLOOR SQ.FTG: UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG: GARAGE SQ. FTG: 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
SYSTEM?
MANUFACTURED HOME
Width: Length: • Year: Pit Set:
Manufacturer:
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: Phone: Fax:
Address:
City State Zip
Inspector: Phone: Fax:
Address: -
City State Zip
SPECIAL INSPECTIONS
❑ BOLTING ❑ CONCRETE ❑ REINFORCEMENT ❑ WELDING
Firm Name: Phone: Fax:
Inspector(s):
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 inure to the property owner.
Print Name Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash ❑ Check 0 Mastercard ❑ VISA 0 Other
Bankcard#: Expires: VIN#:
Authorized Signature:
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REQUEST FOR INSPECTION- Adult Family Home
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3,and 4. Application must be complete to be processed.
//_
SECTION 1-PROPERTY INFORMATION
SITE ADDRESS:_./. /..-.57:9E �s'A.L'f ,11Q (/1114- �ASSSORS TAX/PARCEL#: -
SECTION 2-/APPLICANT INFORMATION j
PROPERTY OWNER NAME: , 4 / Afjii/7,' ,t;'✓.5 DAYTIME PHONEI(6 ' )/ 3' -7g/i"
LICENSEE NAME(IF DDFFEREN1): DAYTIME PHONE:
SECTION 3—FLOOR PLAN
A complete floor plan must indude all sleeping rooms, identified by number(#1, #2, #3 etc.) and all components for
exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
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• SECTION 4—DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge,and that I am authorized by
the owner of the above premises to request inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Social and Health Services and the jurisdiction for the appropriate license(s)to conduct such business at this
location. I further agree to hold harmless the jurisdiction conducting such inspections at my request as to any claim(including costs,expenses,and
attorneys'fees incurred in the investigation of such claim),which may be made by any person,including the undersigned,and filed against the
jurisdiction,but only where such claim arises out of the reliance of the jurisdiction,including its officers and employees,upon the accuracy of the
information supplied to the jurisdiction as a part of this application.
NAME/TITLE: DATE:
PROPERTY OWNER :J APPLICANT 2 LICENSEE