2012, 07-18 Permit App, Checklist EGR-2012-0023 Private LaneSTART DATE:
Updated March 201
11SV-FS21Public Foi
29-11.doc
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Spokane
Valley.
Community Development Department
irmit Center
703 East Sprague Avenue, Suite B-3
pokane Valley, WA 99206
Tel: (509) 720-5240
Fax: (509) 688-003,7. ' '
Derm itcentor(@sDoka n eva Ilev.o rq
(Staff Use Only)
PERMIT No.:
CHECKLIST?: ❑Y ON NIT:
LAND DISTURBANCE PERMIT APPLICATION
TAFF USE
ENGINEERED GRADING
❑ REGULAR GRADING
❑ GRUBBING & CLEARING
APPLICANT USE :
SITE ADDRESS:
ASSESSORS PARCEL NO.:
APPLICANT NAME:
PHONE:
97?-l&�S
Ra S Zi2J 5 c i
EMAIL:
CONTACT NAME (❑ SAME AS APPLICANT) : ./9 YG
PHONE: EMAIL:
PROPERTY OWNER NAME:
MAILING ADDRESS:
Crr :
PHONE:
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STATE: L�
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RECEIVED
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CELL SII P E,1M;T CEN r EH
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SUB # 7-77 RE\ ,--- i
CELL: e.y. -e�
EMAIL: CELL:
0 CHECK IF APPLICANT
ZIP:
CONTRACTOR NAME: (®.TBD): ❑ CHECK IF APPLICANT
MAILING ADDRESS:
CITY:
STATE: ZIP:
PHONE:
STATE LIC. NO.:
EMAIL: CELL:
EXPIRES: UBI:
DESCRIBE THE SCOPE OF WORK IN DETAIL AND INDICATE USE:
kocitd
ESTIMATED QUANTITIES (CUBIC YD): CUT: t j5 FILL:
IF CUT, PROVIDE DESTINATION OF SOIL: OVN, j j 4
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ers\Community Develop
ESTIMATED COMPLETION DATE:
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102 Administration\03 Forms - Official Versions\Permit CenterlLand Disturbance Permit & Checklist 3-
Sikikanel�
LAND DISTURBANCL ,LD) PERMIT CHECKLIST
For Grading, Clearing and Grubbing work outside the Right -of -Way (ROM
(For work within ROW need a ROW permit)
Permit Center ♦ 11703 E Sprague Ave Suite B-3 • Spokane Valley WA 99206
509.688.0197 ♦ Fax: 509.688.0037 ♦ permitcenter@spokanevalley.org
Project Address: 7o/ Ai, rec_S Today's Date: 7/l (I �.
Project Descripti 5LLCV piat-
Signature: Print Name: ',Lk . ,� ScRA/ (-?Ar 5
The purpose of t s checklist is to g er information about the proposed project so to determine what land
disturbance permit, if any, is required by the Spokane Valley Municipal Code.
Starting with Part 1 and working from top to bottom, please answer the following questions.
The first "Yes" identifies the type of land disturbance (LD) permit required.
PART 1 — Is LD work exempted or already covered? (SVMC 24.50.020) If so then LD permit not needed.
❑ Yes [j No Does your project only have to do with emergency utility work; cemetery graves; eliminating
septic tanks; digging out a basement; building a wall less than 4 feet high; disposal of refuse
that is covered under other regulations; already permitted mining, quarrying, stockpiling of
aggregate material (rock, sand, gravel, aggregate, or clay) or exploratory excavations done
under the direction of a licensed engineer or engineering geologists? If yes, then project
exempted from a LD permit.
PART 2 — Engineered Grading Permit needed? (SVMC 24.50.030; 2 sets plans, calcs etc. from Engineer)
® Yes ❑ No Will this grading be for a short plat, subdivision or binding site plan?
❑ Yes IN No Will any grading occur in a FEMA floodplain, wetland, wetland buffer, Fish and Wildlife
habitat conservation area or geologically hazardous area?
❑ Yes y No Will the volume of excavation or fill for the project be over 500 cubic yards? (If checked Yes
then a SEPA environmental checklist will need to be submitted for review)
❑ Yes ® No Will the grading create a base or support for a permanent structure?
❑ Yes El No Will the grading be for a driveway that is longer than 75 feet?
❑ Yes ® No Will any grading occur in a drainage channel or be for a water feature (like a perennial or
intermittent pond) with a surface area greater than 500 square feet?
Yes ❑ No Will this grading result in the addition or replacement (excluding pavement maintenance) of
5,000 square feet or more of impervious surfaces or the disturbance of 1 acre or more land
or the construction of new drywells or other underground injection control (UIC) facilities?
❑ Yes ® No Will any excavations or fills have slopes at 2:1 (H:V) or steeper and heights greater than 2 1/2
feet?
❑ Yes E-No Will any excavations or fills have slopes at 10:1 (H:V) or steeper and heights greater than 4
feet?
PART 3 — Regular Grading Permit needed? (SVMC 24.50.040; 1 set of plans showing grading and
temporary erosion and sediment control; does not require engineering)
❑ Yes ❑ No Will the volume of excavation or fill be over 50 cubic yards on any one lot?
❑ Yes ❑ No Will any excavations have slopes at 2:1 (H:V) or steeper or heights greater than 3 feet?
0 Yes ❑ No Will any fills have slopes at 2:1 (H:V) or steeper or heights greater than 2 feet?
PART 4 — Grubbing and Clearing (G&C) Permit needed? (SVMC 24.50.050; 1 set of plans showing G&C
and temporary erosion and sediment control; does not require engineering)
Yes ❑ No Will the G&C work disturb 5,000 or more square feet of area or remove 7 or more trees?
(Note that forest practices overseen by DNR or commercial agriculture are exempt)
❑ Yes EC No Will there be any clearing on slopes or near/in FEMA floodplains, wetlands, wetland buffers,
Fish and Wildlife habitat conservation areas, geologically hazardous areas or erodible soils?
If the answers to all of the questions above are "No" then a permit is not required for the proposed work.