2015, 05-20 Permit App: RGR-2015-0008 Land Disturbance 1
Community Development Department (Staff Use Only)
• Permit Center
Sciiocokane 11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206 PERMIT No.:
Tel: (509) 720-5240
Valley Fax: (509) 688 0037 CHECKLIST?: ❑Y ON Inn:
permitcenterCa�spokanevallev.orq
LAND DISTURBANCE PERMIT APPLICATION
STAFF USE:
❑ ENGINEERED GRADING % REGULAR GRADING 0 GRUBBING &CLEARING
APPLICANT USE: ' n' , � /
SITE ADDRESS: /Lae 13 L. V &i��iT ' v e-
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ASSESSORS PARCEL NO.: �1 s+ O-126 .01
APPLICANT NAME: Nvt-h Y1 11 1 1 CJJ1+Ya( tU(c I )(lc -
PHONE: (AV)
2,1t'3402-EMAIL: JOlIl& 2e,Avl'HYII ttakImfraCJ ELL: (L )' i..O-
CONTACT
NAME (SAME AS APPLICANT):
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PHONE: EMAIL: CELL: ,C ," .--:'
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PROPERTY OWNER NAME: ii1 ,,,/ ./ a •/ IAA / 4 10. • '=-,�' a, .
Cil ' '4,r��
MAILING ADDRESS: C,0 s . / J� ,,,,,, /
CITY: STATE: Zi /
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PHONE: EMAIL: CELL: O\O\" 3/ ,t. "
CONTRACTOR NAME: (0 TBD): CHECK, PPLICANT
--pMAILING ADDRESS: D. x�444-
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CITY: 'v'no mit ft1 1 c STATE: W ZIP:/ 1-/�t1Zf/1 O�
PHONE:C�DJ)2 tJ 3�Z EMAIL: t&YplA�r,0VI+AAL l Y1N'AGbrr.S.AgdCELL:( g) 22_0- o 1
STATE LIC. NO.: `J EXPIRES: UBI:
DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE:
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m ott\ am cU MY bah spOr-f- va frt . p h r RaN t/ 1644
Cil ia,V10,0, Will Oe .! 51-4 04 DY) uli s I d e oP of prior/1j ofP
\IttIIttuA
ESTIM AIDED QU (CUBIC YD): CUT: 400 FILL: /
IF CUT, PROVIDE DESTINATION OF SOIL:
START DATE: Lt)ti (2( ) ESTIMATED COMPLETION DATE: L/4-121)I
to Irl i /( / .' , LIZ___
f} la4/ i L �
X20
Sig ture: ' Date
Up ed March 2011
C:\Users\pbarclay\Desktop\Customer Information\Grading Permit\Land Disturbance Permit Application.doc
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LAND DISTURBANCE (LD) PERMIT CHECKLIST
Spokane
For Grading, Clearing and Grubbing work outside the Right-of-Way(ROW)
Valli.. (For work within ROW need a ROW permit)
4001000
Permit Center ♦ 11703 E Sprague Ave Suite B-3 ♦ Spokane Valley WA 99206
509.688.0197 ♦ Fax: 509.688.0037 ♦ permitcenter@spokanevalley.org
`�
Project Address: Itl9el 3 - asp Ua.(191NaV Today's Date:G120/2-01,
Project De •tion: 'J
Signature: M. 44 i/ , //A. , Print Name: _ / AS
The purpose f this checklist i to gather information about the proposed project so to determine what land
disturbance permit, if any, is required by the Spokane Valley Municipal Code.
Starting with Part 1 and working from top to bottom, please answer the following questions.
The first "Yes" identifies the type of land disturbance (LD) permit required.
PART 1 — Is LD work exempted or already covered? (SVMC 24.50.020) If so then LD permit not needed.
❑ Yes r.No Does your project only have to do with emergency utility work; cemetery graves; eliminating
septic tanks; digging out a basement; building a wall less than 4 feet high; disposal of refuse
that is covered under other regulations; already permitted mining, quarrying, stockpiling of
aggregate material (rock, sand, gravel, aggregate, or clay) or exploratory excavations done
under the direction of a licensed engineer or engineering geologists? If yes, then project
exempted from a LD permit.
PART 2— Engineered Grading Permit needed? (SVMC 24.50.030; 2 sets plans, calcs etc. from Engineer)
❑ Yes 1 No Will this grading be for a short plat, subdivision or binding site plan?
❑ Yes ►:1 No Will any grading occur in a FEMA floodplain, wetland, wetland buffer, Fish and Wildlife \
habitat conservation area or geologically hazardous area?
111 'Yes No Will the volume of excavation or fill for the project be over 500 cubic yards? ([frpc{ l Yes *c0,0
then a SEPA environmental checklist will need to be submitted-#or revs ‘`' �
❑ Yes No Will the grading create a base or support for a permanent structure?''; 7i fir, (, .�
❑ Yes No Will the grading be for a driveway that is longer than 150 feet? �. ,°'` r .
❑ Yes •R No Will any grading occur in a drainage channel or be for a wat -feattA i*e a r, •i-
intermittent pond) with a surface area greater than 500 sque feet?)
El Yes Yes No Will this grading result in the addition or replacement (excluding pavement m- en ce
5,000 square feet or more of impervious surfaces or the disturb nce of 1 -► e or or and
or the construction of new drywells or other underground injectio cosft� (U f sties?
❑ Yes wl No Will any excavations or fills have slopes at 2:1 (H:V) or steeper an ekc s„ tater than 21,4
feet?
❑ Yes No Will any excavations or fills have slopes at 10:1 (H:V) or steeper and h is greater than 4
feet?
PART 3— Regular Grading Permit needed? (SVMC 24.50.040; 1 set of plans showing grading and
temporary erosion and sediment control; does not require engineering)
hYes ❑ No Will the volume of excavation or fill be over 5.0 cubic yards on any one lot?
❑ Yes J No Will any excavations have slopes at 2:1 (H:V) or steeper or heights greater than 3 feet?
❑ Yes X.No Will any fills have slopes at 2:1 (H:V) or steeper or heights greater than 2 feet?
PART 4— Grubbing and Clearing (G&C) Permit needed? (SVMC 24.50.050; 1 set of plans showing G&C
and temporary erosion and sediment control; does not require engineering)
❑ Yes IkNo Will the G&C work disturb 5,000 or more square feet of area or remove 7 or more trees?
(Note that forest practices overseen by DNR or commercial agriculture are exempt)
❑ Yes No Will there be any clearing on slopes or near/in FEMA floodplains, wetlands, wetland buffers,
Fish and Wildlife habitat conservation areas, geologically hazardous areas or erodible soils?
If the answers to all of the questions above are "No"then a permit is not required for the proposed work.
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CALL.2 BLISINESS DATiS BEFORE Nr011:DIG
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