2006, 12-04 Permit App: 06004722 ROWPermit Center
11707E Sprague Ave. Suite 106
Spokane Valley, WA 99206
Community Development (509)68S-0036 FAX: (509)688-0037
aYww.sookanevalley,org
ROW Construction ❑ Driveway
Permit Application ❑ Sidewalk
Road Obstruction
L(16
PERMIT NU/41113M:
PERMIT FEE:
El Pavement Cut **(see below)
0 Curb & Gutter ❑ Other
0 No ❑ Yes (traffic oontrol plan required)
PROJECT ADA 5 ///
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START DATE i �-- 45 t 4
i1/1a.✓C�
�j ANTICIPATED COMPLETION DATE 1 Z- j 5,0 t tP
Building Owner:
J i't-a,.,1 1t;.0.A ish[..l, tJ
Contractor: Avr'$ t"C., .r la/ 'ia4_
Name:
Name:
Address:
Address: Z.+ -s tp
N, 0 i I (-
City:
State:
Zip:
City:
State: Zip:
Phone:
Pax:Phone:
Pax:
Phone:
Fax: S D9 -SIC/ -0) / l03
Contact
Contractor Lic No:
Exp Date:
Name:
-
City Business Lic. No:
Phone:
Tier
Policy
**MUST BE COMPLETE IF PAVEMENT CUT**
Tvne of Work
Electric
Water
CATV
Communications
Sewer
Other
Asphalt
Width Length
X
X
X
Condition of Cut
Sawcut
Grind (pre -approved only)
Existing Road Condition
Depth of Asphalt
Depth of Gravel
Concrete
Width Length
X
X
X
tis e ( v .1} f a4.' 04'
?: a i \014.- .11C.4 k M- c
'I'' 1.9 2..E.4e3
BOND/INSURANCE CERT #
Signature
Method of Payment:
0 Cash
Bankcard #:
❑ Check
Authorized Signature:
Work completed satisfactorily
RMSIRD 16-4110
I] Mastercard
Expires:
(PER SVMC TITLE 10 ARTICLE 2)
Data
❑ VISA
VINO:
(INSPECTOR)
PLEASE FAX TO CITY OF SPOKANE VALLEY UPON COMPLETION (509)688.0037
Date