2005, 03-01 Permit: 05-692 ROWSooKmannee0*'00�
,;o$Valley
Anticipated start date_
Call 24 hours before inspection required
Phone 509.688-0036 Fax 509.688-0037
Dt EP�RTMENT OF PUBLIC WORKS,
Permit # PW
ROW CONSTRUCTION PE MIT
Location of property_ ` _=_- = �.
-(Address/Parcel*'.if availa
Applicant Name__
Address . o - 0,��I � C.Phone Lt'�
Contractor's Name 'ice &E9 SkLtd I
Address 0.1SQC1 j ,'�Lt / Phone t —q
Contractor's Reg# –&esS i xpires G V
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
E�j .ewer ConnectionF-1Driveway
❑ Curb & Gutter 1-1 Gas Installation
Cable/Conduit F] _ Sidewalk Repair/Construction
Other
Pavement Cut? Dimensions
Bond/insurance certification must be on file with the City. Bond #
SPECIAL CONDITIONS:
Permittee Signature Approved
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card # Expiration Date
Name of Holder Signature
Fees Paid$
(Application) (Inspection)
Date Init
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_ �O /
PERMIT MUST BE KEPT ON SITE