2004, 04-27 Permit App: BLD-04-04203 Tear Off, Reroof is
0441"\ BUILDING PERMIT APPLICATION WORKSHEET
GiT1' City of Spokane Valley Community Development Department
Building Division
40,,Valley 11707 E. Sprague Avenue, Suite 106
ev Spokane Valley, WA 99206
Phone: (509) 688.0036;Fax: (509) 688-0037
REQUIRED SITE INFORMATION
Street Address: `7 ? ,1 , ) t
Assessor's Tax Parcel Number(s): .
Legal Description: IIll eA,ocl r . ' c' f"
PERMIT DESCRIPTION:
Building Permit ❑ Change in Use ❑ Grading ❑ Manufactured Home
0 Relocation ❑ Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
❑ Owner: ❑ Applicant:
Phone: Fax: Phone: Fax:
Address: Address:
City State Zip Code City State Zip Code
❑ Contractor: g0,,ks d Sari ❑ Architect:
Phone: 1 ei 1-557q Fax: Phone: Fax:
Address: Po (3t,A ,-)S.:1441 1 Address:
City State Zip Code City - State Zip Code
WA State Contractor License#: Contact:
PERMIT/BUILDING INFORMATION 1
HEIGHT TO PEAK: DIMENSIONS: #OF STORIES:
MAIN FLOOR TO SQ. FTG: 2""FLOOR SQ. FTG: UNFIN BASEMENT SQ. FTG:
E 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: 1
COS OF PROJECT 30%SLOPES ON PROPERTY: SEWER OR ON-SITE SEPTIC
. ,!900 rv SYSTEM?
MANUFACTURED HOME
Width: Length: Year: Pit Set:
Manufacturer:
RELOCATION
Previous Address:
Proposed Use:
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
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 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 0 VISA ❑ Other
Bankcard #: Expires: VIN#:
Authorized Signature: