2013, 03-18 Permit App: APR-2013-0008 ApproachSpo°'kane
�Ualley
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcenter@spokanevaliey.orq
RECEIVED
RIGHT OF WAY (ROW) PERMIT APPLICATION.
'+82ti13
DRIVEWAY 0 PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
0 CURB & GUTTER 0 OTHER CSV PERtV1JT CENTER
i
0 YES ***'FI
ROAD OBSTRUCTION ❑ NO
PROJECT ADDRESS: ? / /5-
4
DU 1-
:.r
w
RE1RE
•
START DATE: ANTICIPATED COMPLETION DATE:
BUILDING OWNER NAME:
NAME:
L 0 7 -
ADDRESS: / 7 / S S %176 . L" 21 L i)
cm: S F Oev9. /f
PHONE: S Fj z ^ 3-3 fj
STATE: Z-7.7 `1- ZIP:
FAX: CELL:
CONTACT NAME: D n L71 ti' D (=
PHONE: 3� — S X FAX:
CONTRACTOR NAME: /- /2 /'-A-A-
CELL:
MAILING ADDRESS: 66 //
CITY: !U t• !U Clilt Le' 410` STATE: !/��� ZIp: .9'1,0 Z U
PHONE: 2 % 6 L/ () FAX:,�Q%J CELL: 36 S 3 j Zj
CONTRACTOR LICENSE No.: !%� /L /�4CG /2/ 4/IAS: CITY BUSINESS LICENSE NO.:
TIER:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 10 ART CLE 2)
It
SIGNATURE:
DATE: 3 /1?
�3
****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
2C)91 --46C-4
CATV
OP OL U
Comm.
fi p0LO,4C-1l
Sewer
Other
Effective October 28, 2007 Page 1 of 2
http://www.spokanevalley.org/filestorage/124/938/210/948/1496/Right_of Way_(ROW)_Permit_App_1-11-11.doc
i
Asphalt (width X length)
Concrete (width X length)
Locate Ticket #: - - a
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 this 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 Is 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 be s bmitted and subsequently approved before thls application can be processed.
Date: Z//E//3
Signature
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Effective October 28, 2007 Page 2 of 2
http://www.spokanevalley.org/fiiestorage/124/938/210/948/1496/Rlght_of Way_(ROW)_Permit_App_1-11-11.doc