2014, 11-14 Permit App: ROW-2014-0662 Right of Waylv 141401:04p Vietzke
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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)688-0337
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5092440596 p.1
PERNIT
NUMBER
Project # O U Z0/4 -0662-1
IVED
(Staff Use Only: t., 0:
NOV i,
2014
PERNIT I
fEe: CSV PERMIT CENTER
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RIGHT OF WAY (ROW) PERMIT APPLICATION#
APPROACH PAVEMENT CUT (SEE
BELOW) SIDEWALK
CURB & GUTTER / WORK THROUGH
MANHOLE ( OTHER WO > )a- { 4-14 \ /Lis 04 e
ROAD OBSTRUCTION \ NO YES (if yes, complete the following)
% of street or # lanes that will be obstructed:
Length of time street will be obstructed:
c4.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: 1 0 N • 1evwa
APPLICANT'S_JOB 41:
START DATE: 1I— n- Z(J`y -
PROJECT DESCRIPTION:
REV #[ED
PARCEL NUMBER: '/73.1797
LOCATE TICKET # /1346a-6
ANTICIPATED COMPLETION DATE: '(-20-20)'1
Sct Co n1& t — ukt tcia-- d— di — I A.R4t144 F j
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
MAILING ADORERS: QTY: STATE: ZIP:
PHONE:
FAX: CELL:
CONTRACTOR INFORMATION
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MAILING ADDRESS: So IA td!-BLV7( m
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STATE: yvclP: MOO
PHONE: 'SIP:\ -241'1 -GIC FAX: as -9G `nu SO°I-Icv1-0367
CONTRACTOR LICENSE No.: V t e{ ZPt ail... , WIRES: 5'.j=2bt r an BUSINESS LICENSE No.:
BONO/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
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Nov 14 14 01:04p Vietzke
CONTACT NAME:
5092440596 13.2
PMONE:
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK: (Clyde
one)
Gas
Electric
Water
CAN
Communication
Sewer,Other
TYPE OF CUT/REPAIR:
(circle one)
Asphalt
Gravel
Concrete
Other
SIZE OF CUT
(width) x (length)
STAFF TO COMPLETE:
ROAD TIER:
APPLIES?
PAVEMENT CUT POLICY
The penmtte veflfles, acknowledges and agree by their signature that: 1) if this permit is for construction or on a dwelling, the dwSPng Ia/w0
be served by potable water. 2) Ownership of thls City of Spokane Valley permit Inures to the property owner. 3) The signatory is the property
owner or has permission to repressit the property owner In this transaction. a) Ali construction S to bo done In NI 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 Crty of
Spokane Valley permit Is not a permit or approval for any violadon of federal, state or fetal laws, codes or ordinances. 6) Plans Or addltlonal
bdormation may be required to be submittedand subsequently approved before this applka gain can be pre sed,
ECP/RATION
Right-of-way permits Issued between April 1 and Septette 30 are Valid for 30 days after the date of Issuance. with a one -tune 30 -day
extension avalbbI. Ragbt-of-way permits Issued between October 1 and Mardi 31 are valid until the ktbwInq April 30.
Applicant Signature:
Method of payment: Cash Check
Mastercard'*
Date: /1—)1 —281 y
• • If paying with credit card, the City will all for credit card Information when the permit Is ready to be Issued.
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 588-0037 UPON COMPLETION
Reeser 41140014
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