2004, 02-23 Permit App BLD-04-03598 MHS°pokn' e�,•
jUalley
PERMIT APPLICATION WORK SHEET
SPOKANE VALLEY COMMUNITY DEVELOPMENT
BUILDING DIVISION
11707 East Sprague Ave Ste 106
Spokane Valley, WA 99206
Phone: (509)688-0036 Fax: (509)688-0037
REQUIRED SITE INFORMATION
i
ADDRESS: J/9P e.
®CONTRACTOR: / f.Q1A/LP-
PHONE: 9.'.iO3 FAX:
ADDRESS: /S90.4 E ..992AcE J/ ,44.uM M,z7
CITY, STATE, ZIP
WA ST CONTRACTOR LICENSE #
2Q RELOCATION
STREET ADDRESS: //92O C
ASSESSOR'S TAX PARCEL NUMBER(S):
LEGAL DISCRIPTION:
PERMIT DESCRIPTION:
BUILDING PERMIT a CHANGE IN USE a GRADING
SIGN U TENANT
21CIA.NUFACTURED HOME
0 OTHER
OWNER / APPLICANT INFORMATION
°OWNER: C'J7/22,o,t) %L�ya.
APPLICANT:
PHONE: 9Z4 - o>83,3 FAX: PHONE: FAX:
ADDRESS:
CITY,STATE, ZIP CITY, STATE, ZIP
ARCHITECT:
PHONE:
ADDRESS:
FAX:
CITY, STATE, ZIP
CONTACT:
PERMIT/BUILDING INFORMATION
COST OF PROJECT:
BUILDING HEIGHT TO PEAK:
BUILDING DIMENSIONS:
NUMBER OF STORIES:
NUMBER of BEDROOMS:
FLANKING SETBACK:
FRONT SETBACK:
REAR SETBACK:
LEFT SETBACK:
RIGHT SETBACK:
30% SLOPES ON PROPERTY:
OCCUPANCY GROUP:
CONSTRUCTION TYPE:
MAIN FLOOR SQ FT:
2ND FLOOR SQ FT
UNFIN BASEMENT:
STRUCTURES ON PROPERTY: FINISHED BASEMENT:
CRITICAL AREAS: GARAGE:
CURRENT PROPERTY SIZE: COVERED DECK:
CURRENT PROPERTY USE: DECK:
CURRENT SEPTIC USE:
CURRENT WELL USE:
IMPERVIOUS SURFACE AREA:
MANUFACTURED HOME SIGN
WIDTH: 1 LENGTH: %no
YEAR: 13 PIT SET:
MANUFACTURER: %S/GIfIL-1A/:
SQ FT OF SIGN: HEIGHT OF SIGN:
# OF SIGNS: AREA OF EXIST SIGN:
TYPE OF SIGN:
RELOCATION FIRE SAFETY
PREVIOUS ADDRESS:
PROPOSED USE:
FIRE SPRINKLER: FIRE ALARM:
PAINT BOOTH: TENT:
FIREWORKS DISPLAY:
BLASTING: DATE/TIME:
WA 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):
BUILDING STAFF USE ONLY
IS PUBLIC SEWER AVAILABLE: ® YES ® NO
IS PUBLIC WATER AVAILABLE: YES NO
IF YES: COUNTY ® CITY
IF YES, WHICH WATER DIST/IRR:
IS PROPERTY LOCATED WITHIN DESIGNATED STORMWATER CONTROL AREA: ® YES ® NO
IS THE PROPERTY LOCATED WITHIN ASA: ® YES CI NO PSSA: ® YES 0 NO
DATE:
STAFF:
METHOD OF PAYMENT:
0 0
CASH CHECK
VISA
nei�il■�■r�
BANKCARD#; EXPIRES. VIN #
AUTHORIZED SIGNATURE.
*FAXED PERMIT APPLICATIONS WILL ONLY BE ACCEPTED WITH MAJOR BANKCARD
Department of Labor & Industries
Factory Assembled Structures Section
INSTRUCTIONS:
1. Complete all spaces, including the signature box (marked with an X).
2. Draw a map on reverse side of WHITE copy only.
3. Forward completed permit and fees to the nearest L&I office. See list on reverse.
4. Contact and schedule the inspection(s) with the same L&I office per the checklist.
MANUFACTURED/MOBILE HOME
ALTERATION PERMIT
Owner
Address
last name
first name Day time phone
(
Do not
complete
shaded
areas
Installer/Contractor/Dealer
Address
Phone
( )
City
Contractor's registration number
State ZIP+4
Serial Number(s)
HUD Number(s)
Place fee amount in proper box
Mechanical
Heat Pump
Air Conditioning
Furnace Installation (gas or electric)
Gas Piping
Wood Stove ----
Pellet Stove ---- serial No
Gas Room Heater
Gas Decorative Appliance
Range: changing from electric to gas
Gas Water Heater replacement
Water Heater: changing from electric to gas
Plumbing
Fire sprinkler system (also requires a plan review)
Each added fixture
Replacement of water piping system
Structural
Inspection as part of a mechanical installation
(cut truss/floor joist, sheet rocking)
Reroofs (may require a plan review)
Changes to home when additions bear loads on home per
the design of a professional (also requires a plan review)
Other structural changes (may require a plan review)
Fire Safety
Li
I1
Serial No.
Place fee amount in proper box
Electrical
Heat pump
Air Conditioner
Furnace Installation (gas, or electric)
Wood Stove (if applicable)
Pellet Stove (if applicable)
Gas Room Heater
Gas Decorative Appliance (if applicable)
Range: changing from gas to electric
Electric Water Heater replacement
Electric Water Heater replacing Gas Water Heater
Each added or modified circuit
Hot Tub or Spa (power from home electrical panel)
Replace main electrical panel
Low Voltage Fire/Intrusion Alarm
Fire Safety
Miscellaneous
LiPlan review
Reinspection - - - -
Insignia
Original Permit
No.
LANote: This permit expires one year after date of purchase. (Non-refundable)
Work is completed at this time. An inspection is requested.
Work is NOT completed at this time, I will call when ready.
Make check payable to: Dept. of Labor & Industries
FEES DUE $
(-Signature of applicant or authorized representative
F622-036-000 mfgd/mobile home alteration permit 7-02
White -Olympia Canary -Inspector Green -Contractor Pink -Purchaser Goldenrod -Purchaser