2003, 05-14 Permit App BD03-420 MHCity of
SPOKANE VALLEY
PERMIT #
62W 003 (p
frx (f-.0037
BUILDING PERMIT APPLICATION
Box 1 OWNER (c,--tj; cm Orp _ r JOB LOCATION J' C j-r)
OWNER'S ADDRESSCITY°'ThHONE )')toff s-
DESCRIBE JOB
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THIS PROPERTY IS OWNED BY: SINGLE/MARRIED Y
PARTNERSHIP CORP.
BOX 2 CONTRACTOR'S NAME
CONTRACTOR'S ADDRESS
PHONE
CITY
CONTRACTOR'S REG.# UPr-C * ) ?Q c) EXPIRATION DATE /U 461 e
(CARD MUST BE PRESENTED AND COPIED OR VERIFIED)
BOX 3 CONTACT PERSON OF PROJECT
PHONE
ADDRESS CITY ZIP
BOX4 SEWER AVAILABILITY WATER AVAILABILITY
BOX 5 ESTIMATED PROJECT COST $ EXISTING BLDG. VALUATION $
BOX 6 PROPERTY TAX ACCOUNT NUMBER
LEGAL DESCRIPTION
(IF NECESSARY, PLEASE SUBMIT A SEPARATE PAGE WITH THE LEGAL DESCRIPTION) it
CENSUS NUMBER LOT NUMBER
BOX 7 BUILDING SQUARE FOOTAGE (Existing / proposed)
3RD FLOOR / OTHER /
BASEMENT UNFINISHED / DECK
CARPORT / TOTAL /
1ST FLOOR
BASEMENT FINISHED
/ GARAGE
2ND FLOOR
HEIGHT TO PEAK OF BUILDING
FT.
30X8 ( SINGLE FAMILY
( ) MULTIFAMILY (NO. OF UNITS
( ) COMMERCIAL / INDUSTRIAL
( ) TENANT IMPROVEMENT
( ) NEW CONSTRUCTION
( ) EXISTING STRUCTURE
TOTAL AREA OF PROPERTY , SQ. FT.
IMPERVIOUS SURFACE SQ. FT.
IOX 9 PLUMBING FIXTURES (Including rough -ins) MECHANICAL APPLIANCES
PLEASE USE THE ATTACHED PLUMBING / MECHANICAL FORM FOR THE LISTING OF ALL APPLIANCES,
SYSTEMS, HEATING AND AIR UNITS, FIREPLACE INSERTS, WATER HEATERS, CONVERSION BURNERS,
LAWN SPRINKLER SYSTEMS, BACK FLOW PREVENTERS, ET AL.
OX 10 Water Service meter size (if known)
Also see BOX 4
OX 11 Septic Tank — Not generally allowed in the City of Spokane Valley. For special circumstances contact
Your sewer purveyor and the Health District (See BOX 4)
OX 12 Street use may require a " Street Use Permit" for sewer, water, sidewalks, curb cuts. Contact the Public
Works Department.
/ERIFY UNDER THE PENALTY OF PERJURY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND
DRRECT TO THE BEST OF MY KNOWLEDGE AND FURTHER THAT I AM AUTHORIZED BY THE OWNER OF THE
30VE PREMISES TO PERFORM THE WORK FOR WHICH THE APPLICATION IS MADE.
✓'NER/AGENT DATE (OVER)
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card:
Visa Mastercard
---- ---- ---- ---- Expiration Date
Print the name of the Bolder
Signature
• OFFICE USE ONLY - PLEASE DO NOT WRITE BELOW THIS LINE
-------------------------------- —
ZONE SETBACKS: FRONT SIDE REAR
HEIGHT LIMIT
PLANNING DEPARTMENT APPROVAL DISAPPROVAL
DATE
REMARKS
SEPA: EXEMPT NOT EXEMPT
FIRE DEPARTMENT APPROVAL DISAPPROVAL
REMARKS
DATE
PUBLIC WORKS DEPARTMENT APPROVAL
DISAPPROVAL DATE
TYPE OF JOB: NEW RESIDENCE RES. ADD/ALT
NEW INDUSTRIAL IND. ADD/ALT
NEW COMMERCIAL COMM. ALT/ADD NEW MULTIFAMILY
NO. UNITS
MULTIFAMILY ADD/ALT TENANT IMP. ROOF
OTHER
OCCUPANCY TYPE OF CONSTRUCTION
--_STORIES
BUILDING SQ. FT.
BUILDING SQ. FT.
BUILDING SQ. FT.
BUILDING SQ. FT.
TOTAL SQ. FT. TOTAL VALUATION
BUILDING PERMIT NC. PLAN CHECK FEE REC'D
—�_ RECEIPT NUMBER
PERMIT FEE PLAN CHECK FEE PLUMBING FEE
MECH. FEE
TOTAL FEES WSBCC SURCHARGE ENERGY SURCHARGE
OTHER CHARGES ; I AMOUNT DUE
BUILDING DEPARTMENT APPROVAL
. BY
DATE
ASSIGNED ADDRESS
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