2015, 05-29 Permit App: ROW-2015-0301 ROWSpokana
jVall&
Community Development Department
Permit Center •
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcenter@spoka nevalley.orq
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
O APPROACH ❑ PAVEMENT CUT (SEE BELOW) ❑
O CURB & GUTTER ❑ • WORK THROUGH MANHOLE
ROAD OBSTRUCTION : ❑ 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%0 of a local access street, or closes any portion of an arterial street,
then a TRAFFIC PLAN IS REQUIRED ', Pre -Approved TCP Proposed:
PARCEL NUMBER:�{7f • /O/ 9
LOCATE TICKET #
SIDEWALK
OTHER
PROJECT ADDRESS: / q 5 a3 ,[', N of d ill
APPLICANT'S JOB #:
START DATE: c _/12
PROJECT DESCRIPTION: M t 0 F /-fo 0,S iF
145,23 E. morON
ANTICIPATED COMPLETION DATE: ,j —/a
�Ro✓h !6a 9 f, R@SS CT ro
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
Ln RR`/ fbr`�+c�/
MAILING ADDRESS: LI/4D y St; t/G'YZ cITY: r9 too K4,9g - STATE:tci ? ZIP: 99/
020
PHONE: 509- al 1 gy`7 9/ FAX: CELL: 6 9„ '..• 2 7 ?a y7
CONTRACTOR INFORMATION yy�� << r
NAME: t;J R E % TNA //'`T'`l J' r r - A A/ J URI `/ sn
MAILING ADDRESS: /(/ 7 , FELTS CITY: S/"(%• J �P
3 Ci 9— v l 3 _ z 7 / FAX:
PHONE:
CONTRACTOR LICENSE NO.: a R L rs gliVREXPIRES:
STATE: W)A. ZIP: j'990
CELL:
CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME:
d( 7 g R J PHONE:
RECEIVED
CSV PERMIT CENTER
MAY 2 9 2015
Project# RPW-2a!%Ok
Name i7J
Submittal
1
Modified April 14, 2014 - -
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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 pel-mit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additional
information may-tie'required to tie&submitted and subsequently approved before this application can be processed.
EXPIRATION
Right-of-way permits issued between April 1" and September 30`" 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" are valid until the following April 30`".
Applicant Signature:
Method of payment: ❑ Cash ❑ Check
0 Visa**
Date
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
P:\Community Develooment\11 Forms\B. Development Engineering\ROWPA.doc
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