2003, 10-21 Permit App: BLD-03-02842 MH k( J - , ,_
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.000Valky , PERMIT APPLICATION WORK SHEET �;�'-'� l
SPOKANE VALLEY COMMUNITY DEVELOPMENT -
BUILDING DIVISION
9 1 707 East Sprague Ave Ste 106 Jt1}l 4.
Spokane Valley, WA 99206 1 , '`y t, f
Phone:(509)688-0036 Fax:(509)688-0037 1_J.,c
REQUIRED SITE INFORMATION
STREET ADDRESS: I`t 4L,8 E'• `( ILe, !mor c e-vt A G at S Ut)A 990/C
ASSESSOR'S TAX PARCEL. NUMBER(S): 59-19A . (t-105-
LEGAL
t-1d5LEGAL DISCRIPTION: a p pL t Ira.Mei cc-/4l e i ( sr Acid Zaf s s& _3
PERMIT DESCRIPTION: MAIN) uCa.(4-u)r--rte 1--(e LA-ter PIA-re 64.44A41--. P6264J-
O BUILDING PERMIT 0 CHANGE IN USE 0 GRADING grMANUFACTURED HOME
}RELOCATION 0 SIGN E TENANT 0-OE1HER
OWNER / APPLICANT INFORMATION
OWNER: q ATTA-6-1J PI;A/1 Com, ® APPLICANT:
993
PHONE: C 57,;) - 312-SFAX: (S7Fi) 4Z8-6'7(i Lr PHONE: FAX:
ADDRESS: 30651 i•), (-LCL2 e." sr le•4 / 8s8k9 ADDRESS:
CITY,STA1 E,ZIP CITY,STATE,ZIP
®CONTRACTOR: 0 ARCHITECT:
PHONE: FAX: PHONE: FAX:
ADDRESS: ADDRESS:
CITY,.STATE,ZIP CITY,STATE,ZIP
WA ST CONTRACTOR LICENSE# CONTACT:
uPERMIT/BUILDING INFORMATION
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: Soilage system desk: ' `Yv )- -
blt brdrx nni
LEFT SETBACK: CURRENT WELL USE: /0/.4 3
061,'r —'/ / //rctnt.
RIGHT SETBACK: IMPERVIOUS SURFACE AREA:
(////--'L/ f v/./( a:4'r'G4/Q//i.i it/
U-u,.n 47/: rt, IC //eaea
/fes'
Pk;1 r; /3✓,let'.^y f!IA,ri A'.,--t ,
MANUFACTURED HOME • SIGN
WIDTH: a 8 LENGTH: `!$ SQ FT OF SIGN: HEIGHT OF SIGN:
YEAR: /99'7 PIT SET: .-Ad #OF SIGNS: AREA OF EXIST SIGN:
MANUFACTURER: a 1111.44-P Ln 3 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
I SPECIAL INSPECTIONS
® BOLTING ®CONCRETE 0 REINFORCEMENT 0 WELDING
FIRM NAME: PHONE: FAX:
INSPECTOR(S):
I BUILDING STAFF USE ONLY
__I
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: 0 YES 0 NO PSSA: 0 YES 0 NO
DATE: ' STAFF: I
METHOD OF PAYMENT:
® a 0 r - 0
Mk 6,-c1Rl.J
IfISA
CASH CHECK w■wr
BANKCARD#; EXPIRES: VIN#
AUTHORIZED SIGNATURE:
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
f
Department of Labor&Industries 8. sT�TE.o 4
ALTERATION PERMIT
Factory Assembled Structures Section d Do not complete shaded areas
IPett#
INSTRUCTIONS: m "
1. Complete all spaces,including the signature box(marked with an X). ;•: t p:.
2. Draw a map on reverse side of WHITE copy only. �§ , >�'� c,.* z`
�_{ 21 x000„` �4.
3. Forward completed permit and fees to the nearest L&I office. See list on reverseDIS.
4. Contact and schedule the inspection with the same L&I office within 15 days. 9 ., &lgiItk `- >
Owner last name first name Day time phone Date
. 1` _.tW _�r` _ 3
` j_._._.��.__`__.._�City E 'a i !E.i
1 ti t t ZIP
Address State
-'.s, ., q . ; L '%;t” i C f tv ___ 4}' �,L .
Installer/Contractor/Dealer Phone Contractor's registration number
( )
Address City State ZIP+4
Check the appropriate boxes in section A and section B. FEES
A LI Commercial Coach B ❑ Alteration Inspection(check appropriate boxes below) $
•Serial No Air Conditioning/Heat Pump _2 _ <S:E• r '''-'''.•''
Electrical .8;, a t
Electrical Appliances t{i.f r - ..
Mobile Home
Fire Safety 10171/Z:
Serial No '
Gas Furnace .F.
Gas Piping
HUD No. Plumbing
Structural
❑ Recreational Vehicle or Li Park Trailer Wood/Pellet Stove — —rIN01
SenaiNn Plan Review $
RV InspectionLP� $
4.4
Model No ur Plan Approval Ne Reinspection �� * �� $
: `▪ , Technical Inspection $
Note: This permit expires one year after date of purchase. (Non-refundable)
Signature of applicant or authorized representative Make check payable to: Dept.of Labor&Industries_
X 1 FEES DUE $ .. : .),
Department use only a
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