2004, 12-21 Permit App: 04009495 Change of Use Project Number: 04009495 Inv: 1 Application Date: 12/21/2004 Page 1 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
.......................................................................
Permit Use: C OF U FROM RESIDENCE TO ADULT FAMILY Contact: HAVE,PATRICK
HOME-6 LEVEL I CLIENTS Address: 11411 E 19TH AVE
C-S -Z: SPOKANE,WA 99206
Setbacks: Front Left: Right: Rear: Phone: (509)970-8649
Group Name:
Site Information: Project Name:
...............................
Plat Key: 001393 Name: KOKOMO TOWNSITE(FEES) District: Sout
Parcel Number: 45282.2111 Block: Lot:
SiteAddress: 11411 E 19TH AVE Owner: Name: HAVE,PATRICK
Address: 11411 E 19TH AVE
Location::SPO SPOKANE,WA 99206
Zoning: UR-3.5 Urban Residential 3.5
Water District: Hold: ❑
Area: .00 Acres Width: 0 Depth: 0 Right Of Way(ft): 70
Nbr of Bldgs: 1 Nbr of Dwellings: 1
Review
Special InspectionsReleased'By: N
0
Landuse/Zoning Released By.
A,)/et — S/16 A eff12-a.e D( . V
Permits: .....................................................................................................................................................
Building Permit
Contractor: OWNER Firm: OWNER
Phone: (000)000-0000
Item Description Units Unit Desc Fee Amount
CHANGE OF USE/SAFETY INSP 1 SELECT $47.00
STATE SURCHARGE 1 SELECT $4.50
Permit Total Fees: $51.50
Operator: DMD Printed By: DMD Print Date: 12/21/2004
Project Number: 04009495 Inv: I Application Date: 12/21/2004 Page 2 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
No
Payment Summary
Permit Type Fee Amount Invoice Amount Amount Paid Amount Owing
Building Permit $51.50 $51.50 $0.00 $51.50
$51.50 $51.50 $0.00 $51.50
Disclaimer:
Submittal of this application certifies the owner(or person(s)authorized by the owner)has both examined and finds the information
contained within to be true and correct,and agrees that all provisions of laws and/or regulations governing this type of work will be
complied with. Subsequent issuance of a permit shall not be construed to be a permit for,or an approval of,any violation of any of the
provisions of the code or of any other state or local laws or ordinances.
Signature:
Operator: DMD Printed By: DMD Print Date: 12/21/2004
. BUILDING PERMIT APPLICATION WORKSHEET
Snrr01\411%111
kane City of Spokane Valley Community Development Department
Building Division
11707 E. Sprague Avenue, Suite 106
dl Valley Spokane Valley, WA 99206
J Phone: (509) 688-0036; Fax: (509) 688-0037
REQUIRED SITE INFORMATION
$Street Address: I '4(( . • I 4th -Au c • SpoLAA0 � LUU 9 q ZOL
Assessor's Tax Parcel Number(s):
Legal Description:
PERMIT DESCRIPTION: �-t--�--Q--± �0,� J4�(�i2c �' CJS-C�"�5
II] -Building Permit [R Change in Use [l Gra ' 111 Man actured ome
❑ Relocation El Tenant Improvement ❑ Fire Safety ❑ Other
OWNER/APPLICANT INFORMATION
rfr Owner: 0 . 1 ®' Applicant:`�Q i�r1 �Jl._
� � ., s
Phone: .� -61-7,- ; 'x: Phone: t (9S—1 l-T p ax:
Address: RI J) ^1 . Address: , :►j. 1'
IN,1 I Y111 O1(. —(j 7by-D(0J° ( (4(( , ( - • 92 (0
City State Zip Code City State Zip Code
El 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: 2ND 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: , r TOTAL HABITABLE SPACE: IMPERVIOUS SURFACE AREA:
COST OF PROJECT: 30% SLOPES ON PROPERTY: SEWER OR ON-SITE SEPTIC
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 ❑ VISA ❑ Other
Bankcard #: Expires: VIN#:
Authorized Signature:
Vit, ANS MUST BE
KEPT
OCA►
THESE , -t H
E JOB
SITS
OR CODE COMPUANCE
'4E' 3l IMING DIVISION
4,
(ve 07 2tegpv,gyp,
d Y1 4-
-, 01 ---�
'' 1klQYh
s- '-o"
r 3!
dPt
.&---„,-,z}---
kowrz /-06s7--
e.)....Ais.j,,,,....t.7 j
4 ,..suj...a -1._. .
Noes
a
•, b
I-5/i
le
0i ---'9a P
0 \'
\\� \
3'-8
r m - o/-,si .� r.
to
a 1;;701/V‘ k �o /Cl Tc."
1-0
Ls. ., .. \,....
ii
/-G
co
F--,,r-10/ --IP 1
_'..7..,i, ZI id d,
�� _—_� 1
6135-)4)S
t .q r G
Si ti 5 I
1 1. -so
lt, 6, 01/ .4 1,
K--- N i3-)S -r-'°
e le
--,- kl .
1 \i")/ln ._.] 7. I lee' .,
�-„L-,h -s t41'
4--- „s- r - .
i ---,
f Q:L. 42d
II ej j:.51.7,L.r.D
A li
g....
IoM
1
•-- -- v,Z. _--- g F b ,.4. W
M \� l'
w
In
4 2,_$„ ST
O
i
t
!/
•
•
r , P 1 :EZ
+''14eierterretelWV- 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 -
SITE ADDRESS: ///,/// 6- /96-4 147-1/6. - Si F_ ) ASSESSOR'S TAX/PARCEL#: -
SECTTION 2-APPLICANT INFORMATION n .
PROPERTY OWNER NAME: ."/ Wer �� DAYTIME PHONE: �Q3{"�iq7/�/' i g
LICENSEE NAME or DIFFERENT): 7(2,/nek.L.1 / 5 DAYTIME PHONE:0 7-ElbF9 1/ 70
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)
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 costs,expenses,and
attorneys'fees incurred in the investigation of such claim),which may be made by any person, including the undersigned, and filed against the
jurisdiction, 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
p
p he jurisdiction as a part of this application. /�Q�,/ .
NAME/TITLE: i'n"h ,� Pide/z�""''- DATE: 7�/ t. .°/1")q
❑ PROPERTY OWNER K APPLICANT 0 LICENSEE
SECTION 5-INSPECTION CHECKLIST - -
YES NO
Home licensed (or applying for license) on or after July 1, 2001 ❑ ❑
SLEEPING ROOMS ❑ ❑
Sleeping Room #1 ❑ S El NSI ❑ NS2
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the inside ❑ ❑
Smoke alarm is installed in the bedroom El El
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) El ❑
Sleeping room window has a maximum sill height of 44" 0 El
Sleeping Room #2 ❑ S 0 NS1 ❑ NS2
Bedroom door is openable from the outside when locked 0 ❑
Closet doors are readily openable from the inside El ❑
Smoke alarm is installed in the bedroom El El
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) ❑ ❑
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #3 ❑ S 0 NS 1 ❑ NS2
Bedroom door is openable from the outside when locked 0 ❑
Closet doors are readily openable from the inside 0 El
Smoke alarm is installed in the bedroom El ❑
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high; 20"wide) ❑ ❑
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #4 ❑ S ❑ NS1 ❑ NS2
Bedroom door is openable from the outside when locked 0 ❑
Closet doors are readily openable from the inside El ❑
Smoke alarm is installed in the bedroom ❑ El
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high; 20"wide) ❑ ❑
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #5 ❑ S 0 NSI O 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 ❑ ❑
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high; 20"wide) ❑ ❑
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #6 0 S El NSI El NS2
Bedroom door is openable from the outside when locked ❑ El
Closet doors are readily openable from the inside ❑ ❑
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" 0 ❑
GENERAL
Bathroom doors are openable from the outside when locked ❑ ❑
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 ❑ El
Access road and water supply approved by Fire Department ❑ 0
❑ PASSED El CORRECTIONS REQUIRED 0 PERMIT REQUIRED
INSPECTOR: DATE: