2014, 09-22 Permit App: ROW-2014-0513 Trench, BoreProject # kW- O /Li - (8/
RECEIVED
Community Development epartment
Permit Center r��I U Staff Use Only)
11703 East Sprague AveTUe�SOit "L �4 1
curor ct��p7��pp Spokane Valley, WA 99206'1 P MIT NUMBER:
�oIt ne " -" - Tel: (369}-§95-06136 Soq- 7zo- SZvo
Valley Fax: (509)688-0037jv PERMIT CENT (PERMIT FEE:
permitcenter(aspokanevallev.orq
SIJFES :-t E_' REV ,/4evnE 4-- b' /Z1927
RIGHT OF WAY (ROW) PERMIT APPLICATION
big DRIVEWAY Bd&..E D PAVEMENT CUT (SEE BELOW) fl SIDEWALK
Q CURB & GUTTER ® OTHER OPE'.0 ree,UG/!
ROAD OBSTRUCTION in NO YES
PROJECT ADDRESS: /Za 1" /7UL✓!�/?V 2D
START DATE: i6/2D / ANTICIPATED COMPLETION DATE: /D/2-th 1
BUILDING OWNER NAME:7 y) 1ZICULE2 . r l ,
NAME: e. mLG/!5T Sir GJ 1119-).3 cri %/"a!J
ADDRESS: 4/M t//&GGgY V A./0 Be t-'
***TRAFFIC PLAN REQUIRED
CITY: I u 94-7 %, STATE: ia/
zIP: 9837
PHONE: 26-3 enc 7'V3) / FAX: CELL:
CONTACT NAME: (,qac Mu Zk/ 5
PHONE: 2533c. i- t/33
FAX: CELL:
CONTRACTOR NAME: is LizE 7�ZEZ'J 71 L. L.. G . - XYItI) UJit/c LSc5c )
MAILING ADDRESS:
i.370/ zV'- J'T
/j
CITY:-�u/in ,tl
-}}E.2
'- STATE: �Gf- Z
QIP: 9839v
PHONE: 2S3 C/ ZS'? 9 FAX: CELL: 3 zha/- 12.2 2
CONTRACTOR LICENSE No.: 91-dt7-
ox931 Zfrti EXPIRES:-6-40/AI CITY BUSINESS LICENSE NO.: to/ -99'&-15/Z.
TIER:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE RyICLE 2)
SIGNATURE: / j � i�t1f/L DATE: 94 j/
***MUST BE COMPLETE IF PAVEMENT CUT****
TYPE OF WORK
CONDITION OF CUT
TYPE OF
REPAIR
EXISTING ROAD CONDITION
Gas
Sawcut
Asphalt
Depth of Asphalt:
Electric
Grind
(preapproved 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) AU construction Is to be done in full 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 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 0 Check
Bankcard #:
0 Visa ❑ Mastercard
EXP: VIN#:
Authorized Signature:
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
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Effective October 28, 2007 Page 2 of 2
C:\Documents and Settings \rw0011\My Documents\Permits\City of Spokane Valley ROW application.doc
Spokane valley, WA 99016
120 S Holiday Rd
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Figure 6H-6. Shoulder Work with Minor Encroachment (TA -6)
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(14 II)
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Nolo: Seo Tables GM -2 and
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of the symbols and'or
letter codes used In
this figure.
Truck -Mounted
Attenuator
(optional)
y Suffer space
J.
Typical Application 6
t (optional)
113 L
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Page 1 of 1
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S/11/2014