2015, 04-13 Permit App: ROW-2015-0170 ROWSpol�ane
FValley.
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite 8-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
p e rm i tc e n to r@ s p o k a n ev a I l e y. o rq
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
Z APPROACH ❑ PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
❑ CURB & GUTTER 0 WORK THROUGH MANHOLE 0 OTHER
ROAD OBSTRUCTION N NO 0 YES (if yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
b If work closes more than 50% of a local access street, orcloses any portion of an arterial street,
then a TRAFFIC PLAN IS RE�Q/UIRED 0 Pre -Approved TCP Proposed:
PROJECT ADDRESS:We /,ar,toraiy PARCEL NUMBER:
APPLICANTS JOB #. LOCATE TICKET #
START DATE: ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION:
S'4auldrr rPfreAfS_ Rrp/acs
wi' tl,. 4t ffrr n/a/errrilf,
exi's><r'h9 rare/
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME: & ACe ivy ►
MAILING ADDRESS:
CITY: 5 i
STATE:
ZIP: • Z 6
PHONE: -95L1-6 /7�]I - FAX:5:74 .-337'J .CELL: :q-qsy 9/
CONTRACTOR INFORMATION
NAME: ij iW(V,ett/) LcXj $C42. Ccucr'
MAILING ADDRESS: 66 IC A) &Lir,
PHONE: S-01-4-1 t'3- L4) 38
CITY:
STATE: 'W'tgI-
FAX: CELL:
ZIP: / / z�'7
CONTRACTOR LICENSE NO.: tl ; VearagqqAt 9 EXPIRES: CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2): 44 Woo SQS W'
CONTACT NAME: DOW Uptel PHONE: g1-VB3 " 417 38
RECEIVED
CSV FERPIRT CENTER
APR 1 3 2015
Project #_130_111!_101c .Q.y�z- �G
Marne !" L7
Modified April 14, 2014 buumnlal >F
P:\Community Develoomen \11 Forms\B. Development E gineerinq\ROWPA.doc
Page 1 of 2
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK:
(circle one)
Gas
Electric
Water
CATV
Communication
Sewer
Other
TYPE OF CUT/REPAIR:
(circle one)
Asphalt
Gravel
Concrete
Other
SIZE OF CUT
(width) x (length)
STAFF TO COMPLETE:
ROAD TIER:
PAVEMENT CUT POLICY APPLIES?
DISCLAIMER
The permitted verifies, acknowledges and agrees by their signature that: 1) if this permit is for construction or on a dwelling, the dwelling is/will
be served by potable water. 2) Ownership of this City of Spokane Valley permit inures 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) The 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 processed:
EXPIRATION
• Right-of-way permits issued between April S:t.and September 30th are valid' for•30 days after the date of issuance, with a one-time 30 -day
extension available. Right-of-way permits issued between October 1' and March 31't are valid until the following April 30th.
Applicant Signature:
ie
Date: t/—i3 Ar
Method of payment: 0 Cash 0 Check
Qt Visa** 0 Mastercard**
** If paying with credit card, the City will call for credit card information when the permit is ready to be issued.
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
• Modified April 14, 2014 --Page 2 of 2
P:\Community Develooment\11 Forms\B. Develooment Engineering\ROWPA.doc