2011, 04-10 Permit App: 11001005 Reroof Community Development Department
Permit Center (Staff Use Only)
$(l 11703 East Sprague Avenue,Suite B-3 '_ I�c
jjl�; Spokane Valley,WA 99206 PERMIT NUM R:
Tel: (509)688-0036 7
Fax: (509)688-0037 PERMIT FEE: D
480•00 Valley
perm itcenter@sookanevai Iev.orq
REROOF CONSTRUCTION PERMIT APPLICATION
0 COMMERCIAL RESIDENTIAL
SITE ADDRESS: 112.13/i111 t- 32"d Aie- S,poKoJfic.. V&L-� w4 91920
ASSESSORS PARCEL NO.: 14 �,55Ib LEGAL DESCRIPTION: Low 24` 55 c Kok on-a
BUILDING OWNER NAME: ASo r1 , J e� 1 �° �> }�
NAME: Ck-So`r
Lr-j fV
ADDRESS: "12 1 S . k G� I -
CITY: SeOl<C t.V1S•' V C� t STATE: �ti 4� ZIP: `I 0 (G
PHONE: 50q - c91 U - / 3 $ U FAX: CELL:
CONTACT NAME: CA_S
PHONE: FAX: CELL:
CONTRACTOR NAME: c,,j n (Q,{3 o-C
MAILING AD - •
Cm: - TE: ZIP:
PHONE: FAX: •
CONTRACTOR LICENSE No.: EXPIRES: CITY BUSINESS LICENSE NO.:
DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE:
Tear Off Overlay
TOTAL COST OF PROSECT: $ 2OO
DISCLAIMER
The permitted verifies,acknowledges and agrees by their signature that: 1)if this permit is for construction 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) The City of
Spokane Valley permit is not a permit or approval for an • federal,state or local laws,codes or ordinances. 6) Plans or additional
information may be required to be subs -• .' . ntly ap. . ed before this application can be processed.
Signature , Date:
e hod of payment: 0 Cash 0 Check 0 Visa 0 Mastercard
Bankcard #: EXP: VIN#:
Authorized Signature:
Effective October 28,2007 Page 1 of 1
P:\Community Development\02 Administration\03 Forms-Official Versions\Permit Center\Reroof Construction Permit App
10.28.07.doc