2006, 10-25 Permit App: 06004283 Safety Inspect . Permit Center
11707 E Sprague Ave;Suite 106 PERMIT NUMBER: L28.3
1_ . *MTalley Spokane Valley IVA`.9920 r`. 20 PERMIT FEE: /i7.7 (509)688-0036 FAX_(509) ��01-7`
Community Development wr'w.spokanevalleyl.otg
Residential Construction New Construction Accessory Bldg
Permit Application Addition/Remodel n Deck
A I ther: %.r, •I# 1
C:PSE ADDRESS I. 6. /674-6i1 cJAtQrx /hay e 97499,
ASSESSORS PARCEL NO: LEGAL DESCRIPTION:
Building Owner: Contractor:
----TbOho
P Ki. Name:
ame:
�� Address:
Address: /09.10T-7/86 v
City: S O/,-i L State:ivA Zip:9920 City: State: Zip:
Phone: C C� Fax: /i Phone: Fax:
Contractor Lic No: Exp Date:
Contact Person City
n City Business Lic.No:
,C,
Name: /' ( /_,,a.0,-,
Phone: 80—:523/
Describe the scope of work in detail: Cost of Project: $
/V
**************The following MUST be complete: (write N/A if not applicable)**********************
HEIGHT TO PEAK: DIMENSIONS: #OF STORIES: TOTAL HABITABLE SPACE:
MAIN FLOOR TO SQ. 2Nu FLOOR SQ. FTG: UNFIN BASEMENT SQ. FTG: IMPERVIOUS SURFACE
FTG: AREA:
FINISHED BASEMENT GARAGE SQ. FTG: DECK/COV. PATIO SQ. FTG: 30% SLOPES ON
SQ. FTG: PROPERTY:
#OF BEDROOMS: CONSTRUCTION TYPE: HEAT SOURCE: SEWER OR SEPTIC?
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.6) Plans or additional information may be required to be submitted,and subsequently approved before
this application can be processed.
_ re- / Date
o. of Payme t
❑ Cash ❑ Check ❑ Mastercard El VISA
Bankcard#: Expires: VIN#:
Authorized Signature:
REVISED 8/25/2005
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> > I
',>: REQUEST FOR INSPECTION-Adult Family Home
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION
, 1-PROPERTY INFORMATION
slrE ADDRESS: o LLit 1 ASSESSOR'S TAX/PARCEL#k:
-
S9a. 6,1-1 .i si:
SECTION 2-APPLICANT INFORMATION
s 7e /C22)9 DAYTIME PHONE
PROPERTY OWNER NAME 41/,/ pD^`2�/ f
LICENSEE NAME OE
off: l</I'rd 4 i2&r c-�27 DAYTIME PHONE: /1 > /
SECTION 3-FLOOR PLAN
A complete floor plan must Include all sleeping rooms, Identified by number(#1, #2, #3 etc.) and all components for
exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary). _
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al ji,)\rir . _
C(` i tai 1�\' ,�d °3
0-11-1
SECTION 4-DISCLAIMER/SIGNATURE-BLOCK .,
•
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge,and that I am authorized by
the owner of the above premises to request Inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Social and Health Services and the jurisdiction for the appropriate license(s)to conduct such business at this location. I further agree to hold harmless the jurisdiction conducting such inspections at my request as to any claim(Including cost, J and
exp
attorneys'fees incurred In the Investigation of such claim),which may be made by any person,including the undersigned,and filed against the
( jurisdidtion,but only where such claim arises out of the reliance of the jurisdiction,including its officers and employees,upon the accuracy of the
information supplied * e jurisdiction as part of application.s
N /
AME Tlit.E: ),6zfl7 C 1 / DATE: /(2/2.0 .
0 PROPERTY OWNER , APPLICANT 3 LICENSEE
SECTION 5-INSPECTION CHECKLIST
YES NO /
Home licensed (or applying for license) on or after July 1, 2001. ❑ o0 1
SLE 3 r` Z°" ROOMS
Sleeping Room #1 0 S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked ❑ 0
• Closet doors are readily openable from the inside ❑ 0
Smoke alarm is installed in the bedroom 0 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24'high;20'wide) ❑D 0
Sleeping room window has a maximum sill height of 44"
Sleeping Room #2 0 S 0 NS1 0 NS2 0 ❑
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the Inside 0 ❑
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24'high;20'wide) 0 0
0 0
Sleeping room window has a maximum sill height of 44" 0 NS1 0NS2
Sleeping Room #3 0 S ❑ ❑
Bedroom door is openable from the outside when locked 0 0
Closet doors are readily openable from the inside ❑ 0
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openabie area of 5.7 sf. (minimum dimensions-24'high;20'wide) 00 00
Sleeping room window has a maximum sill height of 44"
Sleeping Room #4 0 S 0 NS1 0 NS2 ❑ ❑
Bedroom door is openable from the outside when locked 0 0�
Closet doors are readily openable from the inside 0 r
Smoke alarm is installed in the bedroom
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24'high;20"wide) 0
Sleeping room window has a maximum sill height of 44"
Sleeping Room #5 0 S 0 NSI 0 NS2
Bedroom door is openable from the outside when locked 0 0
Closet doors are readily openable from the inside 0 0
Smoke alarm is installed in the bedroom 0 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) 0❑ 00
Sleeping room window has a maximum sill height of 44"
Sleeping Room #6 0 S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked 0 0
Closet doors are readily openable from the Inside 0 0
Smoke alarm.is installed in the bedroom0 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24'high;20"wide) 00 0
SSleeping room window has a maximum sill height of 44"
• GE ERAL ❑ . ❑
Bathroom doors are openable from the outside when locked ❑ 0
Smoke alarms are installed on all levels of the dwelling
All smoke alarms are audible in all parts of the dwelling upon activation of a single device 0 0
Access road and water supply approved by Fire Department
t
0 PASSED 0 CORRECTIONS REQUIRED 0 PERMIT REQUIR,,
INSPECTOR: DATE: