2014, 10-15 Permit App: ROW-2014-0579 Run CATV CableCommunity Development Department
Permit Center (Staff Use Only)
WE 11703 East Sprague Avenue, Suite B-3•
-h-0a Spokane Valley, WA 99206 PERMIT NUMBER:
TeI:(58g)485-®836 6oq.7Zo-S2.140
�00%11ey� Far: (509) 688-0037 PERMIT FEE:
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RIGHT OF WAY ROW PERMIT APPLICATIO1
D DRIVEWAY F1 OTHER PAVEMENT CUT (SEE BELOW) [� SIDEWALK E D
[j CURB &GUTTER �� � f •i 5 2014
ROAD OBSTRUCTION �^NO 0 YES ***TRAFFIC PLAN REQUIRED
PR03 ECT ADDRESS: L/3 �', TUZE!5? Aef ' •M 3 J UIV I VC E N T E R
START DATE: /D / ANTICIPATED COMPLETION DMEL r--
BUILDING OWNER NAME: L,--'
NAME: LLJ 4-1 e /tS 7— Br U A'5 J1fVG 72)AJ ,
ADDRESS: qIL/ l V14L..LLE V AV A/Ul BG G,.-.n'T4" /Z
ZIP:
PHONE: G..7r� d Lm7'T.I FAX: CELL: j 3 .73
CONTACT NAME: S
p� Ef //W ZjZ/
PHONE: f -5:3O Ga y" 2�3 / FAX: CELL:
CONTRACTOR NAME: FXWA4e 'T''c.iz-4aAA LLC
MAILING ADDRESS: /,:!� 7Z)/ ? V r'4 ,:57 g
CITY: -S L/ n-)A)a-,I- /� STATE: �. r� y� ZIP: 9S3 9�r0
PHONE: 25'3 p / I'" L 9 `1 FAX:.. / CELL: fps✓ 210 / - /YQ L
CONTRACTOR LICENSE NO.: PxAkIr-(�9 l' K EXPIRES: CITY BUSINESS LICENSE NO.:
TIER:
POLICY:
TYPE OF WORK
CONDITION OF CUT
TYPE OF EXISTING ROAD CONDITION
REPAIR
Gas
Sawcut
Asphalt Depth of Asphalt:
Electric
Grind
(preavproved only)
Concrete Depth of Gravel:
Water
CATV
Comm. "
Sewer
Other
Effective October 28, 2007 Page 1 of 2
C:\Documents and Settings\rw0011\My Documents\Permits\City of Spokane Valley ROW application.doc
Asphalt (width X length)
Concrete (width X length)
Locate Ticket *:
X
X
X
X
X
X
X
X
X
X
X
X
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 Inure 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 or
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. S) 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.
Signature Date:
Method of payment: ❑ Cash ❑ Check ❑ Visa ❑ Mastercard
Bankcard *: EXP: VIN*:
Authorized Signature:
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
-1
ZZ- A771W / E -b
Effective October 28, 2007 Page 2 of 2
C:\Documents and Settings\rw0011\My Documents\Permits\City of Spokane Valley ROW application.doc
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