2003, 05-13 Permit App: BD03-397 MH City of CoW- 003p
SPOKANE VALLEY (Fr)( Ipn--0037
PERMIT # .;
BUILDING PERMIT APPLICATION
Box 1 OWNER �=�-- —
rtytstc A 1 . 11i-Judy 1/. /ciA JOB LOCATION 131 z Al. 40,-(640
OWNER'S ADDRESS /312 Al.tth%6wc.CITYS .i / ,yP�HONE
T<n+p. '9ids'cs$ tv.use Can:<.�:v /2d.'pC k e m'ty uaq- P o a y (Bar)23C '23:1(6
DESCRIBE JOB �u f
THIS PROPERTY IS OWNED BY: SINGLE/MARRIED Atkry,ed
PARTNERSHIP CORP.
BOX 2 CONTRACTOR'S NAME OttifiCr PHONE
CONTRACTOR'S ADDRESS Siftlti(� CITY
CONTRACTOR'S REG.# EXPIRATION DATE
(CARD MUST BE PRESENTED AND COPIED OR VETFIED)
BOX 3 CONTACT PERSON OF PROJECT �ci,r PHONEC'e
?36-Z3Yo �, YSY-� 1Yo.S6
ADDRESS $4,..r r ct 5 42&w..c CITY ZIP
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BOX 4 SEWER AVAILABILITY Cc,ph7vi, ars So�y,��r WATER AVAILABILITY
BOX 5 ESTIMATED PROJECT COST$ 63, ooD EXISTING BLDG. VALUATION$ /V,g2.
BOX 6 PROPERTY TAX ACCOUNT NUMBER 1.1574 1. 64,4(7
LEGAL DESCRIPTION
O Ppt,?v ist ek+i l,y P76( TR 3 c f 5 r z P r o f iv-rev-2 'r 'X C,
.tQ !a / r {ate ted.
(IF NECESSARY, PLEASE SUBMIT A SEPARATE PAGE WITH THE LEGAL DESCRIPTION)
CENSUS NUMBER LOT NUMBER
BOX 7 BUILDING SQUARE FOOTAGE (Existing/proposed) 1ST FLOOR /[Ao0 2ND FLOOR /
3RD FLOOR / OTHER / BASEMENT FINISHED
BASEMENT UNFINISHED / DECK / GARAGE /
CARPORT / TOTAL / HEIGHT TO PEAK OF BUILDING /q3FT.
BOX 8 ( SINGLE FAMILY
( ) MULTIFAMILY(NO. OF UNITS ( �C) NEW CONSTRUCTION
( ) COMMERCIAL/INDUSTRIAL ) ( ) EXISTING STRUCTURE
TOTAL AREA OF PROPERTY SQ. FT.
( ) TENANT IMPROVEMENT IMPERVIOUS SURFACE_ SQ. FT.
BOX 9 PLUMBING FIXTURES (Including rough-ins) MECHANICAL APPLIANCES ,-
PLEASE
PLEASE USE THE ATTACHED PLUMBING/MECHANICAL FORM FOR THE LISTING OF ALL APPLIANCES,
SYSTEMS, HEATING AND AIR UNITS, FIREPLACE INSERTS,WATER HEATERS, CONVERSION BURNERS,
LAWN SPRINKLER SYSTEMS, BACK FLOW PREVENTERS, ET AL.
BOX 10 Water Service meter sizeif known) I
( 'f Also see BOX 4
BOX 11 Septic Tank—Not generally allowed in the City of Spokane Valley. For special circumstances contact
Your sewer purveyor and the Health District (See BOX 4)
BOX 12 Street use may require a" Street Use Permit"for sewer, water, sidewalks, curb cuts. Contact the Public
Works Department.
VERIFY UNDER THE PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE
\BOVE PREMISES TO PERFORM THE WORK FOR WHICH THE APPLICATION IS MADE.
)WNER/AGENT A , , 4:,, Lam" DATE 6-- 13- 03 (OVER)
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card:
Visa Mastercard - —___ Expiration Date
Print the name of the Holder Signature
OFFICE USE ONLY-PLEASE DO NOT WRITE BELOW THIS LINE
ZONE SETBACKS: FRONT SIDE REAR HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL DISAPPROVAL DATE
REMARKS
SEPA: EXEMPT • NOT EXEMPT
FIRE DEPARTMENT APPROVAL DISAPPROVAL DATE
REMARKS
PUBLIC WORKS DEPARTMENT APPROVAL DISAPPROVAL DATE
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TYPE OF JOB: NEW RESIDENCE RES.ADD/ALT NEW INDUSTRIAL IND.ADD/ALT
NEW COMMERCIAL COMM.ALT/ADD NEW MULTIFAMILY NO. UNITS
MULTIFAMILY ADD/ALT TENANT IMP. ROOF OTHER
OCCUPANCY TYPE OF CONSTRUCTION STORIES
E BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @
TOTAL SQ. FT. TOTAL VALUATION
BUILDING PERMIT NO. PLAN CHECK FEE REC'D RECEIPT NUMBER
PERMIT FEE PLAN CHECK FEE PLUMBING FEE MECH. FEE
TOTAL FEES WSBCC SURCHARGE ENERGY SURCHARGE
OTHER CHARGES ;I AMOUNT DUE
BUILDING DEPARTMENT APPROVAL BY
DATE
ASSIGNED ADDRESS
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