2003, 04-08 Permit App: BD03-083 MH City of
SPOKANE VALLEY
PERMIT # 3 —d 7
BUILDING PERMIT APPLICATION
Box 1 OWNER 4-14, ie- g4s) JOB LOCATION 1°r z.. ,E £
OWNER'S ADDRESS/22 Null—wt. CITY S?are PHONE '/GB •17-s-13
DESCRIBE JOB sC Pia 6 N r I t L 4Z
THIS PROPERTY IS OWNED BY: SINGLE/MARRIED
PARTNERSHIP ----CORP.-r
BOX 2 CONTRACTOR'S NAME 4.it-4Z- !- PHONE S
CONTRACTOR'S ADDRESS //S2S #J / LIP fey CITY
CONTRACTOR'S REG.# { 0/1-4t •033 PL EXPIRATION DATE 247
(CARD MUST BE PRESENTED AND COPIED OR VERIFIED)
BOX 3 CONTACT PERSON OF PROJECT 2./4,L/, :,, i,•r Is, PHONE '/68 -)7—
ADDRESS CITY ZIP
BOX 4 SEWER AVAILABILITY YDS WATER AVAILABILITY YE
BOX 5 ESTIMATED PROJECT COST$ 0a-z) EXISTING BLDG. VALUATION$
BOX 6 PROPERTY TAX ACCOUNT NUMBER 3$2.4a/• 29 0
LEGAL DESCRIPTION
(IF NECESSARY, PLEASE SUBMIT A SEPARATE PAGE WITH THE LEGAL DESCRIPTION)
CENSUS NUMBER LOT NUMBER
BOX 7 BUILDING SQUARE FOOTAGE (Existing/proposed) 1ST FLOOR//78 / 2ND FLOOR - /
3RD FLOOR- / OTHER / BASEMENT FINISHED /
BASEMENTHED / Bmf--- / GSE /
CAST / TO At / HEIGHT TO PEAK OF BUILDING FT.
BOX 8 ,(x) SINGLE FAMILY ( ) NEW CONSTRUCTION
( ) MULTIFAMILY(NO. OF UNITS ) ( ) EXISTING STRUCTURE
( ) COMMERCIAL/ INDUSTRIAL TOTAL AREA OF PROPERTY SQ. FT.
( ) TENANT IMPROVEMENT IMPERVIOUS SURFACE- SQ. FT.
BOX 9 PLUMBING FIXTURES (Including rough-ins) „/JoL MECHANICAL APPLIANCES
PLEASE USE THE ATTACHED PLUMBING/ CF -
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 size(if known) 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.
I VERIFY UNDER THE PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND
CORRECT TO THE B. S F MY KNOWLEDGE AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE
ABOVE PREMISES TO THE WORK FOR WHICH THE APPLICATION IS MADE.
OWNER/ �•�,�. ` DATE
1181° (OVER)
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card:
Visa MastercardExpiration__ Expiration Date
Print the name of the Holder Signature
DO NOT PLACE ANY BUILDING UNDER POWER LINES OR OVER INCOMING GAS LINES.
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
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
BUILDING SQ. FT. @
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ _
BUILDING SQ. FT. @ =
TOTAL SQ. FT. TOTAL VALUATION
BUILDING PERMIT NO. PLAN CHECK FEE RECD RECEIPT NUMBER
PERMIT FEE PLAN CHECK FEE PLUMBING FEE MECH. FEE
TOTAL FEES WSBCC SURCHARGE ENERGY SURCHARGE
OTHER CHARGES AMOUNT DUE
BUILDING DEPARTMENT APPROVAL /-� BY
DATE
ASSIGNED ADDRESS
Received