2003, 09-11 Permit App BLD-03-02443 MHPROJECT APPLICATION WORK SHEET
SPOKANE COUNTY BUILDING AND PLANNING DEPARTMENT
1026 WEST I3ROADWAY AVENUE
SPOKANE, WA 99260 r 11 l 3
509-477-3675
Street Address: Pinecroft MHP# tZ'j
SPECIFIC SITE INFORMATION
11920 E. Mansfield Spokane, WA
Assessor's Tax Parcel Number(s):
Legal Description:
Project Description:
Building Permit
❑ Relocation
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❑ Change in Use
❑ Grading
ri Manufactured Home Permit
❑ Sign
❑ Tenant (New/Change)
❑ Other
Department Use Only
Water District/Purveyor:
Sewer District/Purveyor
Road width
Setbacks
Front: Rear:
Left: Right:
School District:
Fire District:
Zoning
OWNER/APPLICANT INFORMATION
ing this project
x® Owner:
Douglas Saty
Phone: (509) 891-2581
Fax:
❑ Applicant:
Phone:
Fax:
Mailing Address.
E. 14111 Desmet
Mailing Address:
City, State, Zip
Spokane, WA 99216
City, State, Zip
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.Contractor r, l ` i ,
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Phone
Fax
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❑ Architect/Engineer
Phone
Fax
M dr 1
Mailing address
City, State Zip
1.
City, State Zip
WA Sta Contractor license #
i- -/,-)J Off
Contact name:
PROJECT INFORMATION
Building Information
Building height to peak
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# of stories
/
Main floor sq. ft.
9 Ir)
Unfinished basement sq. ft.
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Dimensions
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Total ha"h 'S space
.12.E
_
2n0 floor sq. ft.
Finished basement sq. ft.
Occupancy group
Construction type
%L% u c r (..! /---fir
Garage sq. ft.
.---
Deck sq. ft.
Cost of project
Heat source (electric, gas, etc.)
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Revised 07/25/03
1
[Manufactured Home
Sign
With.
14ft.
Length:
r L.,
What is the square footage of the sign
face?
How high is the sign?
Year:
1978
Make:
Hacienda
it of signs
Area of existing signs
Relocation
Fire Safety
Previous address
C '‘S C.) k(C-
Li1A
Fire Sprinkler
Tent
Paint booth Fire Alarm
Fireworks display
_
Proposed use ,r
Value
/ �f o
Special Inspections Required?
Non -Residential Energy Code Compliance?
Firm Name
Phone
Plans Examiner
Phone
Inspectors:
Address
Inspector
Phone
❑ Concrete
❑ Welding
❑ Bolting O Reinforcement
Address
ADDITIONAL SITE INFORMATION
Are there structures on the property? ❑ Yes FL.No
Ifyes, identifyn osite plan
What is the current property size? f '� j�irrvt' C
(square feet or acres) /1)e 6 0•( -/''-c Le' 1,--, (4- lP
Is any part of the property within 250 feet of a shoreline?
Ifyes, identfy on site plan CI Yes &No
What is the current use of this property?(t //
Is your property in a designated wildlife habitat area?
❑ Don't know ❑ Yes &No
Will the site be served by a septic system? ❑ Yes .l'1-No
Is any part of the property within a 100 yr flood plain?
Ifyes, ident f nn site plan
0 Maybe 0 Don't know 0 Yes 6-No
Are or will there be wells located on the property?
Ifyes, identify on the site plan ❑ Yes ;14—No
Are there any wetlands, streams or ponds within 200 feet of the property?
1f yes, identify on site plan 0 Yes lNo
Is there evidence of fill or excavation on the property?
0 Yes 'A -No
Are there slopes greater than 30% on the property? (30 ft rise in 100 ft)
(_ %) 0 Yes Q No
Are critical or hazardous materials used or stored on site?
0 Yes da' No
DEPARTMENT USE ONLY
Is the property in a designated Stotmwater Control Area?
❑ Yes
❑ No
Is public sewer available to the site? 0 Yes 0 No
Is the property inside the ASA?
0 Yes
❑ Yes
0 No
❑ No
Is public water available to the site? 0 Yes 0 No
Is the property inside the PSSA?
0 Yes
0 No
Is the property located within 1000 feet of a Natural Resource Area?
❑ Yes ❑ No
Date Received:
Staff Representative:
METHOD OF PAYMENT
VISA
❑ CASH 0 CHECK 0
11C•11E
FAXED PERMITS WILL ONLY BE ACEPTED WITH PAYMENT OF A MAJOR CREDIT CARD
DATE:
BANKCARD NUMBER:
EXPI RES:
AUTHORIZED SIGNATURE:
SUBTOTAL
TOTAL FEE
MAKE CHECKS PAYABLE TO SPOKANE
COUNTY PERMIT CENTER
Revised 07/25/03
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 /
/
• r
Day time pbon,e
( :
City
Installer/Contraitor/Dealer
Address
Phone
( ) •
City
I Date
State ZIP
IContractor'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 ----
Gas Room Heater
Gas Decorative Appliance
Range: changing from electric to gas
Gas Water Heater replacement
Water Heater: changing from electric to gas
Plumbing
IFire 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
$.4044. No.:. • •
Serial No
Place fee amount in proper box
Electrical
Heat pump
Air Conditioner
Furnace InstallationAas orOectric)
Wood Stove (if app41,01 - '—
Pellet Stove (if appfgabid)"'
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 nnnP11
Replace main electrical panel
Low Voltage Fire/Intrusion Alarm
Fire Safety
Miscellaneous
Plan review
Reinspection - - - -
Insignia ‘ ,
f
Other • '
Original Permit
No
Note: This permit expires one year after date of purchase.
UWork is completed at this time. An inspection is requested.
Work is NOT completed at this time, I will call when ready.
(Non-refundable)
Make check payable to: Dept. of Labor & Industries
FEES DUE
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'Signature, of arpolrant o4uthonzetl7resentative
X
eques approvccl.oy Requesttlenied because of :specific .violatitnii or W. ashington rules and regulations..
fl Viol- -',.)ns Inuc,.* be cOire6tici and rernspection requested ithin 20 dyi:Oritieitoticeolviotatiott date: Failure to comply •
• may result p .fties: per 1 tt n noted are shown on an"Alteration/Factory Permit
-"" • • "."'
In u" ,re fo-rnsleq-ired s‘lbmitted 1 lc r- r-"rs•-cc,ion
. L . t LSI .
Tot--4-1---pages
. ,
F622-036-000 mfgd/mobi le home alteration permit 1 -02 White -Olympia Canary -Inspector Green -Contractor Pink -Purchaser Goldenrod -Purchaser