2006, 06-19 Permit App: 06002382 ROWSpokane
' Walley
Community Development
Permit Center
11707 E Sprague Ave, Suite 106
Spokane Valley, WA 99206
(509)688-0036 FAX: (509)688-0037
www.spokanevalley.orn.com
ROW Construction
Permit Application
PERMIT NUMBER: 2,33
PERMIT FEE: d -70
o Driveway o Pavement Cut **(see below)
o Sidewalk o Curb & Gutter o Other
Road Obstruction )(No o Yes (traffic control plan required)
PROJECT ADDRESS / o p/o7 4 G rize,
START DATE
ANTICIPATED COMPLETION DATE
.AiiiiiiatilArT 4 -
Name: 4/7rlt - fl. - 4.a .L0044
Address: F9 6x- 7g,.5-99
City: 5/oa G�lr t./i Zip: 51 17-A
Phone: Fax:
icon""tactEPersou=
Name: 74,/ /Cl/} -S' ` h,ea1 ,7
Phone
**MUST BE COMPLETE IF PAVEMENT CUT**
- ;a .;4
Name: 45 Z4 /DAG -/ 4g -46D n_—
Address: 4 O/31) -Y# g 0_51-7 V
City: 5,0 eI4nt. Zip: 5;197„ z, 3
Phone: i qq44-3:03ax:
Lic No: Da oC)Ceo, (Plirexp. Date: ' - / 3
— 02
City Business Lic No: .
Tier
Policy
Type of Work Condition of Cut
Gas Sawcut
Electric Grind (pre -approved only)
Water
CATV
Communications
Sewer
Other
Type of Repair Existing Road Condition
Asphalt Depth of Asphalt
Concrete Depth of Gravel
Asphalt
Width Length
X
X
X
X
Concrete
Width Length
X
X
X
X
BOND/INSURANCE CERT #
Signature
�A
(PER SVMC TITLE 10 ARTICLE 2)
Date
Method of Payment: (Faxed permit applications will only be ac epted with major bankcard)
0 Cash 0 Check ❑ Mas ercard 0 VISA ither (�
Bankcard #: � Expires: VIN#: /
Authorized Signature:
Work completed satisfactorily
REVISED 10/25105
Date
(INSPECTOR)
PLEASE FAX TO CITY OF SPOKANE VALLEY UPON COMPLETION (509)688-0037