2008, 03-14 Permit App: 08000906 ApproachSjkane
i Millet'
Community Development
Permit Center
11703 E Sprague Ave, Suite B-3
Spokane Valley, WA 99206
(509)688-0036 FAX: (509)688-0037
www.spokanevalley.org
Approach Permit Application
09 o Cp
PERMIT NUMBER-.7nup _
PERMIT FEE:
PROJECT ADDRESS 272/ S. i3/a7-FS
START DATE 3- / `/ - 4 8 ANTICIPATED COMPLETION DATE 3 - 30 - a 8
Building Owner: Fir k /- r n l�k red el '
Name:
Contractor:
Address: 272/ S . /?j ATE S
City: JpoK //et' State: 4J'69 Zip:9920Co
Phone: sL//_9.23(a Fax:
Contact Person
Name: ,(/I en
Phone: $(p CJ -',2,9 et/
PROJECT DESCRIPTION (Provide site sketch)
Residential Driveway
Existing Curb & Gutter
Culvert Installation
Other Conditions
Name: ,Qr//s>LIc (eucrete_
Address: V).7 E Lin
City: Spn
Phone: G'99 , -Ac 7 Far
Contractor Lic No: Date: Cy\1710`6
City Business Lic. No:
State: [.UA Zip: ?pap 7
Commercial/Industrial Driveway
Rural Road Section
Sidewalk Repair/Construction
Bond/Insurance certification must be on file with the city.
DISCLAIMER
The permittee verifies, acknowledges and agrees by their signatures that: 1) If this permit is for construction of or on a dwelling, the
dwelling is/will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the property owner. 3) The
signatory is the property owner or has permission to represent the property owner in this transaction. 4) All construction is to be done in
full compliance with the City of Spokane Valley Development Code. Referenced codes are available for review at the City of Spokane
Valley Permit Center. 5) This City of Spokane Valley Permit is not a permit or approval for any violation of federal, state or local laws,
codes or ordinances. 6) Plans or additional information may be required to be submitted, and subsequently approved before this
application can be process =.
t
Signature
Date 3- 1V -Dei
Method of Payment.
0 Cash 0 Check 0 Mastercard 0 VISA 0 Other
Bankcard #: Expires: VIN#:
Authorized Signature:
Effective October 28, 2007
P.\Community Development\Forms\Building fonns\Approach Permit eff 10-28-07.doc
Project Number: 08000906 Inv: I
Application
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Date: 3/14/2008 Page 1 of 2
Project Information:
Permit Use: RES APPROACH Contact: ARTISTIC CONCRETE
Address: 427 E RICH
C - S - Z: SPOKANE WA 99207
Setbacks: Front Left: Right: Rear: Phone: (509) 999-8097
Group Name:
Site Information: Project Name:
Plat Key: 000000 Name: Range
District: Sout
Parcel Number: 45284.1424 Block:
Lot:
SiteAddress: 2721 S BATES RD Owner: Name: BARAJAS, ELEUTERIO & CARLA
Address: 2721 S BATES RD
SPOKANE VALLEY, WA 99206
Location:: CSV
Zoning: R-2 SF Res Suburban District
Water District: 101 SPO CO WATER DIST#3B Hold: ❑
Area: .00 Acres Width: 0 Depth: 0 Right Of Way (ft): 0
Nbr of Bldgs: 0 Nbr of Dwellings: 0
Review Information•
Review
Driveway/Approach
Permits:
Released By::
Originally Released: 3/14/2008 By: sawallace
Contractor: ARTISTIC CONCRETE
Address: 427 E RICH
SPOKANE WA 99207
Item Description
APPROACH -CONST IN ROW
Approach
Firm: ARTISTIC CONCRETE
Phone: (509) 999-8097
Units Unit Desc
1 NUMBER OF
Fee Amount
$50.00
Permit Total Fees: $50.00
Operator: JD Printed By: jmm Print Date: 3/14/2008
Project Number: 08000906 Inv: 1
Notes •
Application
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Date: 3/14/2008 Page 2 of 2
Payment Summary.
Permit Type
Approach
Fee Amount Invoice Amount Amount Paid
Amount Owing
$50.00 $50.00 $0.00 $50.00
$50.00 $50.00 $0.00 $50.00
Disclaimer:
Submittal of this application certifies the owner (or person(s) authorized by the owner) has both examined and finds the information
contained within to be true and correct, and agrees that all provisions of laws and/or regulations governing this type of work will be
complied with. Subsequent issuance of a permit shall not be construed to be a permit for, or an approval of, any violation of any of
the provisions of the code or of any other state or local laws or ordinances.
Signature:
Operator: JD Printed By: jmm
Print Date: 3/14/2008
Mar 14 2008 3:03PM ALL LINES ASSOCIATES INC. 509-326-5567
p.2
ACORDT CERTIFICATE OF LIABILITY INSURANCE
rM
DATE (AI IaNDMYY)
03/14/2008
PRODUCER Phano' (509)327-1658
All Lines Associates, Inc.
1504 W. Northwest Blvd.
Spokane, WA 99205
License #: 180705
INSURED
Artistic Concrete Surfaces, LLC
427 E Rich Ave
Spokane, WA 99207-1644
I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURERA Nationwide Mutual Insurance Co
INSURER e
NAIC #
INSURER
INSURER 0
LIMIT]
INSURER E
Y
V THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINC
ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W TH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 0
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCF
POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR
LTR
ADO
NSRO
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
PATE IMM' DITYI
POLICY EXPIRATION
DATE IMMIDDIYYI
LIMIT]
A
Y
GENERAL
X
LIABILITY
CORMERCLAL GENERAL LIAB'IITY
ACPACT07551277339
03/1412008
04/0312009
EACH OCCURRENCE
5 1,000,000
a cccuree
PREMISES Erc
$ 100,000
CWMS MADE 1^ OCCUR
MED EXP (Any one person)
PERSONAL SADV INJURY
$ 5,000
5 1,000,000
GENERAL AGGREGATE
$ 2,000,000
$ 2,000,000
GENT AGGREGATE LIMITAPPLIES PER
X POLICY 12a LCC
PRODUCTS - CONP!OPAGG
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCH-DULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per PerSEE)
BODILY INJURY
(Per accdent)
$
$
PROPERTY DAMAGE
(Per accdan0
5
GAR
AGE LIABILITY
ANY AUTOOTFERTHMJ
AUTO ONLY- EA ACCIDENT
$
EA ACC
1
AUTOONLY AGG
$
EXCESS/UMBRELLA
LIABILITY
OCCUR I CLAMS MADE
DEDUCTIBLE
RETENTION 5
EACH OCCURRENCE
5
AGGREGATE
5
$
$
WORKERS COMPENSATION AND
EMPLOYERS' LJABIl1TY
ANY ROPNIEIDR RJEXECUTNE
OFPCERMIE IABER EXCLUDED,
n ye; describe under
SPECIAL PROVLSIONSble*
WG STATU1 DT4-
1ITORY LIMITS ER
EL EACH ACCIDENT
$
E L DISEASE • EA EMPLOYEE
E 1 DISEASE - PODGY LIMIT
$
$
OTHER
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES I EXCLUSIONS ADDED DY ENDORSEMENT 1 SPECIAL PROVISIONS
Certificate holder is listed as additional Insured.
CERTIFICATE HOLDER
CANCELLATION
CITY OF SPOKANE VALLEY
11707 E SPRAGUE, #106
SPOKANE, WA 99206
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER SILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT, OUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
AUTMOBIZED REPRESENTATIVE
VOn
(TGM)
ACORD 25 (2001/08)
MAR 14 2006 13:47
t ACORD CORPORATION 1988
Printed by TGM on March 14. 2008 at 02:37PM
509 326 5567 PAGE.02
Mar 14 2008 3:03PM ALL LINES ASSOCIATES INC. 50S-326-5567
P. 3
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or atter the coverage afforded by the policies listed thereon.
ACORD 25 (20011081 .
MAR 14 2008 13:47
Printed byTGM on March 14. 2008 at 02:37PM
509 326 5567 PAGE.03
11 s �F OH
X41
FrG p
cLtd
r
Safb�i S •IZLt
24
1 s Fr
B
Wd Dk
{19
24S r24 24
P •
u
-
Ln 4
G
a
F
w
1` 20
/IC to
0
LA
e•
PLANNING DEPT. APPROVED
6
BYl ttii'1 r,': _,(? A t HSA,c /1--
[-: ATE Jo -
RECEIVED
o -
RECEIVED BYI rev
CIIY>ff sl'OK/,
NO"! 16 2001
-RMIT CENTER
aY�