2003, 09-04 Permit App: 03-02387 Adult Family Home crrt•Oe
ne • I '
,Valley
PERMIT APPLICATION WORK SHEET
SPOKANE VALLEY COMMUNITY DEVELOPMENT
BUILDING DIVISION
11707 East Sprague Ave Ste 106
Spokane Valley, WA 99206
Phone:(509)688-0036 Fax:(509)688-0037
IREQUIRED SITE INFORMATION
STREET ADDRESS: 77 ,_ ,7 ,/,� / S &A i .L.42 ! ,4 i , , ,,t---6C9---/-2,<_./J t4.a,,,r/ , W C/{_
ASSESSOR'S TAX PARCEL NUMBERS : 1
LEGAL DISCRIPTION: -4 _ ` • .4 A ,A, r In 1✓ / A AAR
PERMIT DESCRIPTION: '� ,��„d,<, / ;-r7,{/
®BUILDING PERMIT 0 CHANGE IN USE 0 GRADING a MANUFACTURED HOME
®RELOCATION ®SIGN ®TENANT 0 OTHER
I OWNER / APPLICANT INFORMATION r
IllikCC
® OWNER jO �� /Y4/ �l .,tV ® APPLICANT: /( �� /
PHONE: 9;4 b 'A 7 AX:/9 Y PHONE: FAX:
ADDRESS:)'J /-2;q , ) �S d / _ ADDRESS:
. -(,'r ('J j J / qITY,STATE,ZIP CITY,STATE,ZIP
® / t t'U 1 gAi'LEl-
CARCHITECT:
CONTRACTOR:
PHONE: FAX: PHONE: FAX:
ADDRESS: ADDRESS:
CITY,STATE,ZIP CITY,STATE,ZIP
WA ST CONTRACTOR LICENSE# CONTACT:
PERMIT/BUILDING INFORMATION I
COST OF PROJECT: 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: STRUCTURES ON PROPERTY: FINISHED BASEMENT:
NUMBER of BEDROOMS: CRITICAL AREAS: GARAGE:
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:
IMANUFACTURED HOME , , SIGN
WIDTH: LENGTH: SQ FT OF SIGN: HEIGHT OF SIGN:
YEAR: PIT SET: #OF SIGNS: AREA OF EXIST SIGN:
MANUFACTURER: TYPE OF SIGN:
RELOCATION FIRE SAFETY
PREVIOUS ADDRESS: FIRE SPRINKLER: FIRE ALARM:
PAINT BOOTH: TENT:
PROPOSED USE: FIREWORKS DISPLAY:
BLASTING: DATE/TIME:
WA 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):
BUILDING STAFF USE ONLY
IS PUBLIC SEWER AVAILABLE: 0 YES NO IF YES: ° COUNTY ° 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: 0 YES 0 NO PSSA: 0 YES 0 NO
IDATE: ' STAFF:
METHOD OF PAYMENT:
CASH CHECK L_ - immilmi
BANKCARD#; EXPIRES: VIN#
AUTHORIZED SIGNATURE.
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
. CITY OF SPOKANE VALLEY
BUILDING DEPT.
riPERMIT NUrBER -b--LEa'_2M_______
CO ADDRESS 2,. —i n . Aok, ,,pot
PLANS FL; ._ ' I c .,.b._ ' ' AAA./
Clvti OWNER Statt )
DATE SUBMITTED DATE APPROVED
- APPROVED BY
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