2004, 06-04 Permit App: BLD-04-04492 MH.0"%%,
*lane
deo/Valley
BUILDING PERMIT APPLICATION WORKSHEET
City of Spokane Valley Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
Spokane Valley, WA 99206
Phone: (509) 688-0036; Fax: (509) 688-0037
REQUIRED SITE INFORMATION
Street Address: 10-S 9 -
Assessor's Tax Parcel Number(s): 1/5 f 9 3 `/ 1/ 1
Legal Description: Qcnt Trt b 1 A L-0 t 1 / - 13/-004-.1
PERMIT DESCRIPTION:
❑ Building Permit
❑ Relocation
❑ Change in Use ❑ Grading ❑ Manufactured Home
❑ Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
Owner: `emQirke[.17Cic(�ftA�uPo %ORm(❑ Applicant: Seyouv
Phone:'q i– S(nv' Fax: 9 a-aa.(oe Phone:
Address: tho3 'YI , 1_00wice. Address:
Fax:
c;, rtinkaigittlLua 9 nolo
State Zip Code City State Zip Code
El Contractor: �U,�, �fmis) — ❑ Architect:
Phone: F : Phone: Fax:
Address: Address:
city
State
WA State Contractor License #:
Zip Code
City
Contact:
State Zip Code
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK:
DIMENSIONS, i
X.5 Go
# OF STORIES:
MAIN FLOOR pg,SQ. FTG:
2"" FLOOR SQ. FTG:
UNFIN BASSrT SQ. FTG:
FINISHED BASE NT SQ. FTG: jc
v(
GARAGE
aS(Q. F�%
DECK/COV.. PATIO SQ. FTG:
OCCUPANCY GROUP::
CONSTRUCTION TYPE:
HEA�'rS0 RCE:
# OF BEDROOMS
TOTAL IIAABITAjBLE PACE:
SLLOPES
IMPERVIOUS�eSURFACE AREA:
COST OF PROJECT:
°
30% QNt$ROPERTY:
EWER 0 ON-SITE SEPTIC
7°6.D°
MANUFACTURED HOME
Width: Di
Length: 5 (49 Year: a.00'4 Pit Set:
Manufacturer: 'Fbeet W 0 0 C.�.
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler:
Tent:
Valuation: Above/Underground Storage Tank Size:
# of Heads: Fire Alarm:
Paint Booth:
Fireworks Display: Blasting: Date/Time:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
•Phone:
Fax:
City State
Inspector: Phone: Fax:
Address:
Zip
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING 111 CONCRETE
Firm Name:
❑ REINFORCEMENT
Phone:
Inspector(s):
Fax:
❑ WELDING
DISCLAIMER
The permitee verifies, acknowledges and agrees by their signature that: 1) If this permit is for construction of or on a
dwelling, the dwelling is/will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the
property owner. 3) The signatory is the property owner or has permission to represent the property owner in this
transaction. 4) All construction is to be done in full compliance with the City of Spokane Valley Development Code.
Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) This City of Spokane Valley
Permit is not a, permit or approval for any violation of federal, state or local laws, codes or ordinances.
Ownership of resulting development rights granted by any issued permit inure to the property owner.
Print Name Signature
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash ❑ Check ❑ Mastercard ❑ VISA ❑ Other
Bankcard #: Expires: VIN#:
Authorized Signature:
ADDOESS
Eco Iowa
RO FRONI-�,,.'
COVAMENISmv
REVIEW
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This site plan is being submitted tor the pipes* of
obtaining a building perms and is a true and correct
representation of the proposal. known property
e
lines/dimensions, curb lines, stNdl$fire es a� ,
have been identified. Also indicated al gyp,
bodies of wa r, steep slopes et other
glgnsd:
pste.,;y