2005, 04-06 Permit App: 05001087 Safety Inspect Ci 1 DV(
BUILDING PERMIT APPLICATION WORKSHEE1
CITY ,_ City of Spokane Valley Community Development Departmen
Spokanne 9
Buildin Divisior
11707 E. Sprague Avenue, Suite 10E
4000ValleY
Spokane Valley, WA 9920E
Phone: (509) 688-0036; Fax: (509) 688-003;
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REQUIRED SITE INFORMATION
Street Address: 73/ 5- S Ce/l Av q ��4 r..) : ‘ z , Mta
Assessor's Tax Parcel Number(s):
Legal:Description: - '0
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,PI
PERMIT DESCRIPTION: ,<C4-f re--t T.I ,��ti7;k� (�, TIF an�',Jc.)� ( ,,),_-_,y)<,-7--; /0
ri Building Permit ❑ Change in Use • El Grading [' Manufactured Home
❑ Relocation ❑ Tenant Improvement ❑ Fire Safety ❑ Other
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OWNER/APPLICANT INFORMATION
. ❑ . Owner: /ti o SCA-044/(\) ❑ Applicant:
Phone: cf',7ZX a5 Fax: Phone: • Fax:
Address: /3i3- _c, ,wvq-rte/g nL,O Address:
Ep/( y4 L Cr� (,,J,,,c_ 996,S'7
city State Zip Code City State Zip Code
❑ Contractor: ❑ Architect:
Phone: Fax: Phone: . Fax:
Address: Address:
City State Zip Code City State Zip Code
WA State Contractor License#: Contact: •
PERMIT/BUILDING INFORMATION
HEIGHT TO PEAK: DIMENSIONS: . #OF STORIES:
MAIN FLOOR.TO SQ_FTG: . - -.2"`'FLOOR SQ. FTG: ..;-UNFIN BASEMENT SQ. FTG:
FINISHED BASEMENT SQ. FTG: GARAGE SQ. FTG: DECK/COV. PATIO SQ. FTG:
OCCUPANCY GROUP: CONSTRUCTION TYPE: HEAT SOURCE:
#OF BEDROOMS: TOTAL HABITABLE SPACE: IMPERVIOUS SURFACE AREA:
COST OF PROJECT: 30% SLOPES ON PROPERTY: SEWER OR ON-SITE SEPTIC.
SYSTEM?
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MANUFACTURED HOME
Width: Length: . Year: Pit Set: •
Manufacturer:
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RELOCATION
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Previous Address: . •
Proposed Use: •
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FIRE SAFETY
Fire Sprinkler: # of Heads: Fire Alarm: Paint Booth:
Tent: • Fireworks Display: Blasting: Date/Time: .
Valuation: Above/Underground Storage Tank Size:
WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE
Plans Examiner: Phone: Fax:
Address:
City State Zip
Inspector: Phone: Fax:
Address:
City State Zip
SPECIAL INSPECTIONS
❑ BOLTING ❑ CONCRETE ❑ REINFORCEMENT ❑ WELDING
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Firm Name: Phone: Fax:
Inspector(s):
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 reviewatthe 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
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Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash • ❑ Check ❑ Mastercard ❑ VISA ❑ Other
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Bankcard #: Expires: VIN#:
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Authorized Signature: