2004, 03-11 Permit App: BLD-04-03738 Remodel#01\1.3/4
*Mane
4,o0Valley
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:
1/0212 $T /itloodru Ff f7`
Assessor's Tax Parcel Number(s):
Legal Description: /
PERMIT DESCRIPTION: Parley ane/ / 2 dderl1
Building Permit
❑ Relocation
❑ Change in Use ❑ Grading ❑ Manufactured Home
❑ Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
Er Owner: OfM. Mezirif ❑ Applicant:
Phonef9. g'9/. *RR Fax: .01. ,e•2-/9/ Phone:
Addres�ss: 024 5.' GVoad�ff J?` Address:
die_ WA 997410
City State Zip Code City State Zip Code
Fax:
❑ Contractor:
Phone: Fax:
Address:
City
State Zip Code
WA State Contractor License #:
❑ Architect:
Phone: Fax:
Address:
City State Zip Code
Contact:
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK:
DIMENSIONS:
# OF STORIES:
MAIN FLOOR TO SQ. FTG:
/3110
2"" FLOOR SQ. FTG:
/701)
UNFIN BASEMENT SQ. FTG:
/WO
FINISHED BASEMENT SQ. FTG:
GARAGE SQ. FTG:
DECK/COV. PATIO SQ. FTG:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
HEA, rrUR yycf
# OF BEDROOMS:
TOTAL HABITABLE SPACE:
IMPERIOUS SU1:2FACE AREA:
COST OF PROJECT: 1 to
30% SLOPES ON PROPERTY:
SEWER OR ON-SITE SEPTIC
SYSTEM? ?Ezt' C
MANUFACTURED HOME
Width:
Manufacturer:
Length: Year: Pit Set:
RELOCATION
Previous Address:
Proposed Use:
FIRE SAFETY
Fire Sprinkler:
Tent:
# of Heads: Fire Alarm:
Paint Booth:
Fireworks Display: Blasting: Date/Time:
Valuation: Above/Underground Storage Tank Size:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner:
Address:
Phone:
Fax:
City
Inspector: Phone:
Address:
State
Fax:
Zip
City
State
Zip
SPECIAL INSPECTIONS
❑ BOLTING ❑ CONCRETE
Firm Name:
❑ REINFORCEMENT
Phone:
I nspector(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)
9 Cash 9 Check 9 Mastercard 9 VISA 9 Other
Bankcard #: Expires: VIN#:
Authorized Signature:
External MBA Program®— Effective Business Decisions — P520 W
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