2005, 09-28 Permit App: 05003532 ROWSpokane
,r,,ll*Va.11ey
Call -?-x houf before inspection required
Phone 509.688-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
Anticipated start date _09-28-05 Permit #
ROW CONSTRUCTION PERMIT
LOCATION OF PROPERTY- 622 n Dick Rd.
Applicant Name
(Address/Parcel #, if available)
Avista Utilities Fax 534-2463
Account #
555
Address 1411 E. Mission Ave. Spokane, Wa. 99202 – Katy msc46 Phone 509-495-4152
Customer's Name Avista
Address
Contractor's Reg.#
Phone
Expires
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
Sewer Connection ❑ Driveway
Curb & Gutter F-1 Gas Installation/Repair
x� Cable/Conduit/Pole ❑ Sidewalk Repair/Construction
a Water Installation/Repair 0 Other
Pavement Cut Dimensions
Bond/insurance certification must be on file with the City. Bond #
SPECIAL INSTRUCTIONS: install a new pole at above address, 0 asphalt job #687166905
Permittee Signature_KCC
Approved
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 Init
(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
Date