2015, 02-12 Permit App: ROW-2015-0062 Emergency Water RepairVL IL IV# IV. 1
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Community Development Department
Permit Center
11703 East Sprague Avenue, Sulte B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
per_mitcenter(i:lsookanevalley,orq
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW PERMIT APPLICATION
❑ APPROACH
❑ CURB & GUTTER
ROAD OBSTRUCTION
VPAVEMENT CUT (SEE BELOW) ❑
0 WORK THROUGH MANHOLE ❑
62(NO 0 YES (if yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
b If work closes more than 500/0 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:4L0� _ PARCEL NUMBER:
APPLICANT'S JOB #: LOCATE TICKET #
15 ANTICIPATED COMPLETION DATE: 2143/is
Livi&e_c,6A)c-Y 63A -re- 4_ 5-6ev/C-&
SIDEWALK
OTHER
START DATE:
PROJECT DESCRXPTIO :
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS:
CITY:
STATE! ZIP:
PHONE:
FAX:
CELL;
CONTRACTOR INFORMATION
NAME: VERA WATER & POWER
MAILING ADDRESS: PO BOX 630
PHONE; (509)924-3800
CONTRACTOR LICENSE NO.:
CITY: SPOKANE VALL STATE! WA ZIP! 99037
FAX!
509)922-3929
CELL:
EXPIRES:
CITY BUSINESS LICENSE NO.:
BOND INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME: TODD I-IARMON
Pow -70 5'0062
PHONE: 509 924-3800
Modified April 14, 2014
C:\Users\th@rrnon.VERAWP\DecUments\Spokane Valley ROWPA.doC
Received Time Feb, 12. 2015 10:17AM No.1485
Page 1 of 2
VG IL IV, 1 V. I VrLC1
**** IF PAVEMENT_CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK;
(circle one)
Gas
Electric
CATV
Communication
Sewer
Other
TYPE OF CUT/REPAIR:
(circle one)
Asphalt
Gravel
Concrete
Other
SIZE OF CUT
(width) x (length)
r X /
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
PISCLAIMEF
The permitted verifies, acknowledges and agrees by their signature that: 1) If thls 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 inures to the property owner. 3) The signatory Is the property
owner or has permission to represent the property owner In thls transaction. 4) All construction Is to be done In full compliance with the Clty of
Spokane Valley Development code. Referenced codes are available for review at the Clty 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.
EXPIRATION
Right-of-way permits Issued between April 1" and September 30th are valid for 30 days after the date of Issuance, with a one-time 30 -day
extension available. Right-of-way permits Issued between October 1' and March 31" are valid until the following April 30`".
Applicant Signature -
kr
Method of payment: LJ Cash 0 Check
Date:
0 Visa** 0 Mastercard**
**If paying with credit card, the City will call for credit card Information when the permit Is ready to be Issued.
/S
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Modified April 14, 2014 Page 2 of 2
:\Users\tharmon,j(FRAW_P\Documents\Spokane Vallev ROWPA.dot
Received Time Feb.12. 2015 10:17AM No.1485
* Communication Result Report ( Feb. 12, 2015 11:43AM ) * *
Date/Time: Feb, 12. 2015 11:42AM
File
No. Mode
Destination
P. 1
1) Spokane Valley Permit Center
2)
Pg (s) Result
Page
Not Sent
14$$ Memory TX 99223929 P. 2 OK
Reason for error
E. 1) Hang up or 1 i ne fa i 1
E. 3) No an swe r
E. 5) Exceeded max. E—ma size
E. 2) Busy
E. 4) No facsimile connection
City of Spokane Valley
Community Development
11703E Sprague Ave, Suite S3
Spokane Valley, WA 99206
(509) 7205240
permltcanterekspokaneva0ev,RO
ROW -2015-0062 DE -ROW
PROJECT NAME: ISSUED: 0201212048
SITE ADDRESS: 13905E MALLONS SPOKANE VALLEY EXPIRES:
PROJECT DESCRIPTION: EMERGENCY WATER REPAIR
PARCEL-
APPIJCANT: VERA WATER & POWER -INVOICE OWNER: VERA WATER a POWER -INVOICE
PO BOX 630 VERADAIE, WA9903? PO BOX 630
509922-3929 VE011DAIE. WA99037
5099223928
OWNER ACTING AS BUILDER:
VERA WATERPOWER
PO 000 630
VERADALE, WA 60037-0333
LRmnu: OWNER
Expires:
FEES:
Right of Way
Totals:
$210.00
5210.00
CONDITIONS
Pdol to excaVeton, b 1s Ire Contractor responsibiliyto contact the purveyor of any transmission pipeline that is within 100
feel of permitted work, es par RCW 19.122.033.
For work blocktrg less than 5095 of a focal access street the contractor, at a minimum, la required to have Construction
Ahead signs placed ahead of the work zone. Nom —if It turns out that the work blocks mon than 5015 of a local access
street 19011 Iva permitls not valid and the contractor must submm0 a traffic tweed pan to me Cly for revlewlacoepmnce prior
to continuance of the work. A0 traffic control ehal follow MUTCD standards.
`For pavement ruts, es -bulk drawings (using the current Inland Hortensia Regional Pavement Cut Policy template) are
requited to be submitted b the RIght-o0-Way Inspector, Scat Wallace, w1ON 15 working clays of work being completed. As-
bu(la shall be erbmlted by email (m awelace.apokanevalley.org), by Fax (509-921-1008) wiry dropping o0 et the Penek
Centel.
• M pavement CUD RUM the City of Spokane Valley righter -way shall comply wittthe amen adopted Inland Northwest
Regional Pavement Cut Policy, was emended.
• Al pavement mpalre shall be inspected by the Citta ROW inspector. Scot Wallace (moble: 509-369-5373). The
Contractor Mal notify Mr. Wallace a minimum ot24 tours in advance of the paving.
Pn y u.. Bud., M M212151.3M
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