2005, 09-30 Permit App: 05003589 ROWSpokane e�
#Valley
Call 24 hours before inspection required
Phone 509.08-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
3SePi
Anticipated start date 10/3/05 Permit #
ROW CONSTRUCTION PERMIT
LOCATION OF PROPERTY- 4201 S Hatherly
Account #
(Address/Parcel #, if available)
Applicant Name Avista Utilities Fax 534-2463
Address 1411 E. Mission Ave. Spokane, Wa. 99202 — Ann msc46 Phone 509-495-2244
Customer's Name Michael Johnson
Address Phone
Contractor's Reg.# Expires
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
Sewer Connection Driveway
Curb & Gutter x Gas Installation/Repair
Cable/Conduit/PoIe Sidewalk Repair/Construction
Water Installation/Repair Other
Pavement Cut Dimensions
Bond/insurance certification must be on file with the City. Bond #
SPECIAL INSTRUCTIONS): Install 100 ft of gas service off main located south of Hatherly
Job # 246172963 Loc# 5329726
Permittee SignatureAKC Approved
Date
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card # Expiration Date
Name of Holder Signature
Fees Paid$ 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)
Date
Permit `not valid until One -Call Notification Ticket # entered here
PERMIT MUST BE KEPT ON SITE