2014, 11-07 Permit App: ROW-2014-0646 ROW*po ne
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Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
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(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
APPROACH
CURB & GUTTER
PAVEMENT CUT (SEE BELOW)
' WORK THROUGH MANHOLE
t
SIDEWALK
OTHER
ROAD OBSTRUCTIONNO DYES (if yes, complete the following)
TTTT • % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
c If work closes more than 50% of a local access street, or closes any portion of an arterial street,
then a TRAFFIC PLAN IS REQUIRED Pre -Approved TCP Proposed:
PROJECT ADDRESS: /7loDS E eztaz
APPLICANT'S JOB #: / Z 5-3 (f Lz-
(1_,CiQ PARCEL NUMBER:
LOCATE TICKET #
START DATE: //1/40/r y
PROJECT DESCRIPTION•
� ANTICIPATED COMPLETION DATE: /7/24,//
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PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS:
CITY: STATE:
ZIP:
PHONE:
FAX: CELL:
CONTRACTOR INFORMATION
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MAILING ADDRESS: Po 6 ay_ (a Z( 9 CITY: 5190 Rfr Ai F
PHONE: j '3399 t- 3 /Z.-77_
NAME:
CONTRACTOR LICENSE NO.: 5 fO y:, 4'Dab 9q L Cr.
STATE: t 4_ ZIP: 99ai 7
FAX: 6o') cin -2- CELL:
EXPIRES: 3/, 5/1 s CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME:
U1 2 t I 1.-(.0 >2- N S. f(LL
PHONE:
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RECEIVED �
NOV 'J 0 7 2014
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Modified April 14, 2014 Page 1 of 2
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NATURE OF WORK:
(circle one)
TYPE OF CUT/REPAIR:
(circle one)
SIZE OF CUT
(width) x (length)
STAFF TO COMPLETE:
ROAD TIER:_
VE
Gas
ENT CUT • COMPLETE T
Electric
Water
CATV
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FOLLOWING ****
Communication
Sewer
Asphalt Gravel
Concrete Other
PAVEMENT CUT POLICY APPLIES?
Other
DISCLAIMER
The permitted verifies, acknowledges and agrees by their signature that: 1) If this permit Is for construction owner.perty 3)Thedwelling,
signatoryli ,he dwelling tellproperty
be served hasby potable water. p ownership of this Coity of wner Inokane thistranslley action. 41) Inures
All constructions to be done infull compliance with the Clty of
oVpermission to rnt code. the property
Spokane Valley Development code. Referenced codes are available for review at the Clty of Spokane Valley Permit Center. 5) The Clty of
nrorrmatlon imay berrequiredtta o pemit or approval for
and subsequently approved before this application can tion of federal, state or local laws,
ordinances. 6) Plans or additional
can be processed.
EXPIRATION 30 days
extension availlaablel. Right-of-way permits Issued betwd een Octobetember r 1a and Marchr31'r are valid ountil the followingiAprII30tth a one-time 30 -day
Applicant Signature:
Date:
Method of payment: 0 Cash 0
Check Ly Isa** ❑ 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
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