2014, 06-05 Permit App: ROW-2014-0263 Centurylink WorkCommunity Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permltcenter1suokanevallev. orq
RIGHT OF WAY (ROW) PERMIT APPLICATION
DRIVEWAY PAVEMENT CUT (SEE BELOW) ❑ SIDEWALK
11110 CURB & GUTTER OTHER
ROAD OBSTRUCTION 15t NO 0 YES ***TRAFFIC PLAN REQUIRED
PROJECT ADDRESS: '7JO. F1 £ `1%%GJu L- (.L.c._Q__
START DATE: (/G,/i 4 ANTICIPATED COMPLETION DATE:
BUILDING OWNER NAME: ��-iiir e
NAME:
ADDRESS:
CITY:
STATE: ZIP:
PHONE: Fax:
CELL:
CONTACT NAME
PHONE:
FAX: CELL:
CONTRACTOR NAME:
. �, 1,4 A N F lam k rc4 � 44-6 L. E , 1 --ti e -
MAILING ADDRESS: P 0 1p Z--' 9
CITY: Q, 42 A-'01.) >r- STATE: L,(.,),E�-. ZI.P: c ---N a �
PHONE: 1 .SO 1 — q93-1zl z. FAX: I '' Q `1 "' -2..52 -5 CELL:
CONTRACTOR LICENSE NO.: EpoLA -he Ogg`c EXPIRES: 3/i$J/.S
TIER:
CITY BUSINESS LICENSE NO.:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 10 ARTICLE 2)
SIGNATURE:
DATE:
****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
cCOnlnl
7
-ni2,
Sewer
Other
Effective October 28, 2007
P:\Community Development\L1 Forms\B. Development Engineering\ROWPA,doc
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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 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 Inure to the property owner. 3) The signatory (s the property
owner or has permission to represent the property owner In this transaction. 4) All 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 beubmltted and subsequently approved before this application can be processed.
Signature�L L� Nal/ Date: (�,/co I/
Method of payment: 0 Cash 0 Check D Visa ❑ Mastercard
Bankcard #: EXP: VIN#:
Authorized Signature:
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
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