2004, 01-14 Permit App: BLD-04-03408 Remodel CITY OF 1110d#e\aik
..r.Val'
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: N ' /-014- V Y a /
ASSESSOR'S TAX PARCEL NUMBER(S):
• LEGAL DISCRIPTION:
PERMIT DESCRIPTION:
G EUII;DING.PERNTT. a CHANGE IN USE •.a GRADING a.MANUFACTURED HOME
[I RELOCATION ®SIGN TENANT OTHER
IOWNER / APPLICANT INFORMATION
a -
l
DOWNER: ja.SOVI. Ic( lM 1/0- ® APPLICANT: c <�e 1 2 (�,/l 1-4-e 147L-
PHONE: 6124 -C.P l.P I I FAX: PHONE: 61�'I.'(Q Le lei FAX:
ADDRESS: N1 , 1-4-1/4 (Ala 1 k blJ !&)A.r ADDRESS: �J. 41 ` et IV CI51)ket
STATE,Z� ;tie 'f Wet
CITY,STATE,ZIP
®.CONTRACTOR: Se(f _ ARCHITECT:
PHONE: 99I "LP 19 FAX: PHONE:
PHONE: FAX:
I
ADDRESS: ( fVLQ Cil OU V�� ADDRESS:
CITY,STATE,ZIP CITY,STATE,ZIP
WA ST CONTRACTOR LICENSE# CONTACT:
PERMIT/BUILDING INFORMATION
COST OF PROJECT:/13D0 .rw'S7 30%SLOPES ON PROPERTY: MAIN FLOOR SQ FT:
BUILDING HEIGHT TO PEAK: OCCUPANCY GROUP: 2ND FLOOR SQ FT:.
BUILDING DIMENSIONS: CONSTRUCTION TYPE: UNFIN BASEMENT:
NUMBER OF STORIES: •N9WJ-14-t- STRUCTURES ON PROPERTY: FINISHED BASEMENT:
NUMBER of BEDROOMS: CRITICAL AREAS: ^_
FLANKING SETBACK: CURRENT PROPERTY SIZE: COVERED DECK:
FRONT SETBACK: CURRENT PROPERTY USE: DECK:
REAR SETBACK: CURRENT SEPTIC USE:
LEFT SETBACK: CURRENT WELL USE:
RIGHT SETBACK: IMPERVIOUS SURFACE AREA:
I MANUFACTURED HOME SIGN
WIDTH: LENGTH: SQ FT OF SIGN: HEIGHT OF SIGN:
YEAR: PIT SET: #OF SIGNS: AREA OF EXIST SIGN:
MANUFACTURER: TYPE OF SIGN:
IRELOCATION FIRE SAFETY
PREVIOUS ADDRESS: FIRE SPRINKLER: FIRE ALARM:
PAINT BOOTH: TENT:
PROPOSED USE: FIREWORKS DISPLAY:
BLASTING: DATE/TIME:
,......m...... ........j
1 WA STATE NON-RESIDENTIAL ENERGY CODE
PLANS EXAMINER: PHONE: FAX:
ADDRESS:.
CITY,STATE,ZIP
INSPECTOR: PHONE: FAX:
ADDRESS:
CITY,STATE,ZIP
• SPECIAL INSPECTIONS il
0 BOLTING ®CONCRETE 0 REINFORCEMENT 0 WELDING
FIRM NAME: PHONE: FAX:
INSPECTOR(S):
BUILDING STAFF USE ONLY 1
IS PUBLIC SEWER AVAILABLE: 0 YES ® NO IF YES: 0 COUNTY 0 CITY -
IS PUBLIC WATER AVAILABLE: 0
YES 0 NO IF.YES,WHICH WATER DIST/IRR:
IS PROPERTY LOCATED WITHIN DESIGNATED STORMWATER CONTROL AREA: 0 YES 0 NO
IS THE PROPERTY LOCATED WITHIN ASA: ® YES 0 NO PSSA: 0 YES 0 NO
IDATE: I STAFF: I
METHOD OF PAYMENT:
--- II ��
0 ® masbvainti VISA
CASH CHECK � �-
BANKCARD#; EXPIRES; VIN#
AUTHORIZED SIGNATURE'
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
�°1� ft, 11707 East Sprague Avenue,Suite 106 509-688-0036-Phone
psoi4. ` .ne Spokane Valley,WA 99206 509-688-0037-Fax
Walley For Inspections, call 509-688-0054
Plumbing Permit Application
PROJECT i J • PERMIT
ADDRESS: 1\\ , I 1 �a /► L 1 f USE:
OWNER: l(A`'�tv� 4 If 6 , fkt (wt, PHONE(Daytime Contact): q i - 0 % /9
MAILING ADDRESS: ' 4\
•, I 14 Ala 1 IM,t' okri,ri/ RUQ.- cf7-00
(street) (ci / e (ZIP)
ty )
CONTRACTOR: 5e( .r LICENSE#:
MAILING ADDRESS: PHONE#:
^^
(street) (city/state) (LIP)
PLUMBING FIXTURES
DESCRIPTION DETAILS #OF UNITS X COST EQUALS AMOUNT
1 TOILETS WATER CLOSET,BIDETS X $6 - 4 Co
2 URINALS X $6 -
3 TUBS X $6 =
4 SHOWERS(PER TRAP) BATH,STALL,ON-SITE BUILT X $6 - 0
5 SINKS LAVS/BASINS,BAR,FLOOR KITCHEN,
LAUNDRY,UTILITY,JANITOR,PHOTO,X- X $6 -
RAY,FOOD,PREP/CULINARY/MEAT
6 DISHWASHER X $6 -
7 CLOTHES WASHER X $6 -
8 GARBAGE DISPOSAL X $6 -
9 WATER SOFTENER X $6 -
10 ELECT.HOT WATER TANK NOTE:IF GAS,SEE MECHANICAL X $6 -
11 FLOOR DRAINS AREA,CASE,COIL,TRENCH,CONDENSATE X $6 -
12 FOUNTAINS,DRINKING X $6 -
13 WATER PIPING/DRAIN-IN INSTALLATION,ALTERATION,REPAIR,
WASTE,VENT,PLUMBING REVERSALS X $6 -
REVERSAL
14 SEWAGE EJECTOR GRINDER,SUMP PUMP X $6 -
15 WATER USING DEVICE ICE AND/OR COFFEE MAKER,HOSE BIB,
STEAMER,PROOFER CARBONATOR, X $6 -
SWAMP COOLER
16 CROSS CONNECTION DEVICE VACUUM BREAKER,CHECK VALVE,AND X $6 -
R.P.B.P.D.FOR:VATS,TANKS,BOILERS
17 SPRINKLER SYSTEM X $25 =
18 INTERCEPTORS GREASE TRAP,SAND TRAP,CHEMICAL X $6 -
HOLDING TANK
19 MEDICAL GAS per outlet NITROUS,OXYGEN X $6 -
20 MISC.PLUMBING FIXTURE X $6 -
SUBTOTAL:
METHOD OF PAYMENT /!Y�y
-`9°
AMMO , . !..-
• gfe.5 c PLUS PROCESSING FEE:
0 CASH 0 CHECK 0 cam 0 .._._.....f,-..-.
TOTAL PERMIT FEE DUE:41...0;,
\r�+`4,,A
or DATE: EXPIRES:
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
,
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