2004, 04-02 Permit App BLD-04-03963 MH1
SpoKANECougY
PROJECT APPLICATION WORK SHEET
SPOKANE COUNTY DIVISION OF BUILDING & CODE ENFORCEMENT
1026 WEST BROADWAY AVENUE
SPOKANE, WA 99260
509-477-3675
Street Address: I ( G� Z
Assessor's Tax Parcel Number(s):
Legal Description:
SPECIFIC SITE INFORMATION
F Mckv.s.).t'13
Project Description:
❑ Building Permit
❑ Relocation
❑ Change in Use
❑ Grading
Manufactured Horne Permit
❑ Sign
❑ Tenant (New/Change) ❑ Other
Department Use Only
Water District/Purveyor.
School District
Sewer District/Purveyor
Road width
Fire District:
Zoning
Setbacks
Front:
Rear
left Right:
Ei (Tuner. Pt.�t�4+'(�
4 ,V') r (� t t6'
Mailing Address:
OWNER/APPLICANT INFORMATION
El ',aria'? uda should he ,ontacted revarrlinn lhir hrninY
Phone:
Fax:
City, State, Zip
❑ t acurc Phone
Nlailing address
City, State Zip
Fax
❑ Applicant:
Mailing Address:
Phone:
Fax:
(:itt', State, Zip
❑ Architect/Engineer
Mailing address
Phone
Fax
\CA State Contractor license #
City, State Zip
Contact name:
Building height to peak # of stories
Dimensions
PROJECT INFORMATION
Building Information
Main floor sq. ft. Unfinished basement sq. ft.
Occupancy group
Cost of project
Total habitable space
2'ai floor sq. ft.
Finished basement sq. ft.
Construction type
Garage sq. ft.
Deck sq. ft.
I Icat source (electric, gas, etc.)
Viftigk4�!. ,Fa.ell4.Le
Manufactured Home
,r
Sign
Width:
/
1.ength:
w
What is -the square footage of the sign
face?
1 low high is the sign?
Year:
r
NIak -:
# of signs
Area of cs;sting signs
Relocation
Fire Safety
'Cent
Precious address
Paint booth
Fire Sprinkler
Fireworks display _
Dire Alarm
_
Proposed use
\ .Lin,
Special Inspections Required?
Non -Residential Energy Code Compliance?
Firm Name Phone
flans Examiner Phone
Inspectors:
\ddress
Inspector Phone
0 Concrete 0 Welding 0 Bolting 0 Reinforcement
Address
ADDITIONAL SITE INFORMATION
Are there structures on the property? 0 Ycs 0 No
If yes, identify on site plan
Is any part of the property within 250 feet of a shoreline?
If yes, identify on site plan ❑ Ycs 0 No
Is your property in a designated wildlife habitat arca?
0 Don't know ❑ Yes 0 No
Is any part of the property within a 100 yr flood plain?
Ifyes, identify on site plan
0 Maybe 0 Don't know 0 Yes 0 No
Are there any wetlands, streams or ponds within 200 feet of the property?
If yes, identify on site plan 0 Ycs 0 No
Are there slopes greater than 30% on the property? (30 ft rise in 100 ft)
(%) ❑Yes ❑No
What is the current property sire?
(square feet or acres)
What is the current use of this property?
Will the site be served by a septic system? 0 Ycs 0 No
Are or will there be wells located on the property?
Ifyes, identify on the site plan 0 Yes 0 No
Is there evidence of fill or excavation on the property?
❑ Ycs ❑ No
Are critical or hazardous materials used or stored on site?
❑ Ycs ❑ No
DEPARTMENT USE ONLY
Is public sewer available to the site? 0 Ycs 0 No
Is the property in a designated Stormwater Control Arca?
❑ Yes ❑ No
Is the property inside the ASA?
❑ Yes ❑ No
❑ Yes ❑ No
Is public water available to the site? 0 Ycs 0 No
Is the property inside the PSSA? 0 Yes 0 No
Date Received: Staff Representative:
Is the property located within 1000 feet of a Natural Resource Arca?
❑ Yes ❑ No
METHOD OF PAYMENT
VISA
0 CASH ❑ CI IECK ❑ ❑ � ` 0
FAXED PERMITS WILL ONLY BE ACEPTED WITH PAYMENT OF A MAJOR CREDIT CARD
DATE: I?XPIRIS:
BANKCARD NUMBER:
\UTI IOR1ZI:D SIGNATURE:
SUBTOTAL
TOTAL FEE
MINIMUM PERMIT FEE IS SR1AA0 PLEASE•.
MAKE CHECKS PAY'AI3LE. TO SPOKANE
COUNTY PERMIT t73N'I'ER