2004, 08-26 Permit App: BLD-04-07492 Tear Off, Reroof r
BUILDING PERMIT APPLICATION WORKSHEET
Sillliaise City of Spokane Valley Community Development Department
Building Division
1170 .7 E. Sprague Avenue, Suite 106
. • ev • • Spokane Valley, WA 99206
• Phone: (509) 688-0036;Fax: (509) 588-0037
REQUIRED SITE INFORMATION. • • .
Street Address: / OO/ .S7 li S J - �`,• f I . .6
Assessor's Tax Parcel Number(s): . • .
Legal Description: •. •
PERMIT DESCRIPTION: / ear . Q
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Building Permit ❑ Change in Use ❑ Grading ❑ Manufactured Home
Relocation ❑ Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
❑ Owner: L- a I .IVe. LpA plicant:
- Phone: � ❑ p
Cid,)-7//1 Fax: • C/a�- 7/!/ Phone: Fax:
Address: /OO/ e, /c tI' `• - Address:
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I• • Mate Zip Cope City ,State Zip Code
❑ Contractor: OC)IA`e r
• �❑ Architect: •
Phone:
Fax: Phone: Fax:
Address: . • Address:•
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City State Zip Code City. - State Zip Code
WA State Contractor License#: Contact: •
' PERMIT/BUILDING. INFORMATION • • •
HEIGHT TO PEAK • DIMENSIONS: #OF STORIES:
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- MAIN FLOOR TO SQ: FTG: 2"'t FLOOR SQ.FTG: UNFIN BASEMENT SQ. FTG:
F 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:^�"l • 30%SLOPES ON PROPERTY: SEWER OR ON-SITE SEPTIC
5 /S-W` 00 • SYSTEM?
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MANUFACTURED HOME
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Width: Length: Year:' Pit Set: ••
Manufacturer: .
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. • RELOCATION • :
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. : Previous Address: .
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Proposed Use: •••
FIRE SAFETY •
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• Fire Sprinkler: # of Heads: • Fire Alarm: Paint.Booth:.
Tent: • Fireworks Display: Blasting: • . . Da.telTime:
Valuation: • Above/Underground Storage Tank Size:
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WASHINGTON STATE NON-RESIDENTIAL ENERGY CODE .
Plans Examiner: Phone: Fax:
Address: •
City State Zip
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Inspector: Phone: Fax:
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Address:
City State . Zip
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SPECIAL INSPECTIONS•
❑ BOLTING 0 CONCRETE • ❑ REINFORCEMENT ❑ -WELDING
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Firm Name: . . Phone:. Fax:
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Inspector(s): .
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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 offSpbkane 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.
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Print Name Signature
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Method of Payment: (Faxed permit applications will only be accepted with major bankcard).
❑ Cash ❑ Check r E Mastercard . • 0 VISA _ • 0 Other
• Bankcard#: S •. Expires:' .VIN#:
Authorized Signature: .