2004, 03-16 Permit: BLD-04-0140 ROWSpokane
galley
Call 24 hours before inspection required
Phone 509.688-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
Anticipated start date Permit # 04-140 Account #
ROW CONSTRUCTION PERMIT
Location of property 1121 S. Edgerton Rd.
(Address/Parcel #, if available)
Applicant Name Alla Patinskaya Fax
Address 4236 E. 27th Ave. Spokane, Wa. 99223 Phone 509-535-0990
Contractor's Name
Address
Phone
Contractor's Reg.# Expires
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
Sewer Connection r? Driveway
Li Curb & Gutter
7 Cable/Conduit/Pole
❑ Water Installation/Repair
nPavement Cut
[1 Gas Installation/Repair
Sidewalk Repair/Construction
Other
Dimensions
Bond/insurance certification must be on file with the City. Bond #
SPECIAL CONDITIONS: Construct driveway approach per Spokane County Standards as
adopted by the City of Spokane Valley.
See attached Provisions
Permittee Signature Approved
Date : -/ 6 -Ott
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card #
Name of Holder
Signature
Expiration Date
Fees Paid$ 25.00
25.00
Date !nit
(Application) (Inspection)
In addition to the permit application fee of $16.00 (utility) or $25.00 (construction), inspection on
each permit will be billed to the permittee at a rate of $50.00 per hour with a $25.00 (1/2 hour)
minimum. Permittee signature constitutes an agreement to these terms and provisions.
Work completed satisfactorily (Signed)
Permit not valid until One -Call Notification Ticket # entered here
Date
PERMIT MUST BE KEPT ON SITE