2015, 03-10 Permit App: ROW-2015-0113 ROW103/10/2015y15:47 FAX 5094832525
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SPOKANE DITCH AND CABLE -> VALLEY
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
germltcenferCla sookanevallev.orq
IQ 001
RIGHT OF WAY ROW PERMIT APPLICATION
Y APPROACH
CURB & GUTTER
PAVEMENT CUT (SEE BELOW)
WORK THROUGH MANHOLE
ROAD OBSTRUCTION tg NO l YES (If yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
If work closes more than 50% of
then a TRAFFIC PLAN IS REQUIREDtre Approved TCP Pr
local cPoss street, or closes posedn of an arterial street,
PROJECT ADDRESS: /ao Nom,,,
ntot, fee APPLICANT'S JOB #: /5 p zcje N PARCELLOCATE TICKET NUMETR:
START DATE: 31/3/,5 ANTICIPATED COMPLETION DATE: 3
PROJECT DESCRIPTION: /3D/7 S
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1 DA_ — �I C_ L 7°
SIDEWALK
OTHER
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS:
CITY:
PHONE:
STATE: up;
FAX: CELL:
CONTRACTOR INFORMATION
NAME: <ef1O Kft-1.1EtT tit- ' C.^t fM_I, _Lc C_
MAILING ADDRESS: (Q 6 fly a 9 CITY: 5 fe.,
�a l+;uF ware: km_ zzP; cj�'/2.l'
PHONE: 1 . o 9— q y-3 -/ 2._-7 2._ FAX; per' 9 j-'qH 3 —Z -g i S CELL:
CONTRACTOR LICENSE NO.: 5(01441 1O CIL) LC EXPIRES: 3,4 51 5 CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME: Lit Ge_.I —7-14. %2-NSQ PHONE:
--- ,So 9 — y y 3 -, /`-7
RECEIVED
CSV PERMIT CENTER
Project # - 7 0j3
Name -21
Submittal
Modified April 14, 2014 ------._I
htto: //www.sookanevallev.ora/fllestoraoe/124/938/210/948/1496/2831/ROW PA.doc
Received Time Mar. 10. 2015 1:31PM No. 1580
Page 1 of 2
03/10/2015 15:47 FAX 5094832525
SPOKANE DITCH AND CABLE -> VALLEY
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
[A 002
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.
gXPIRATIory
Right-of-way permits Issued between April 1" 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 31se are valid until the fallowing April 30th.
Applicant Signature:
Method of payment: 0 Cash 0 Check
•// 1,t2.. rz_s'ti
isa
Date: 3 )/O//S
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
htto://www.sookanevallev.oro/filestoraa_e/124/93$/210/948/1496/2831/RQWPA doc
Received Time Mar. 10, 2015 1:31PM No. 1580
Page 2 of 2
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Received Time Mar. 10. 2015 1;31PM No. 1580