2015, 03-09 Permit App: ROW-2015-0109 Shoulder WorkCITY e
so* Val ley
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite 8-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcenter(asookanevallev,orq
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY ROW PERMIT APPLICATION
Q APPROACH 0 PAVEMENT CUT (SEE BELOW)
CURB & GUTTER WORK THROUGH MANHOLE
ROAD OBSTRUCTION 154 NO D YES (if yes, complete the following)
S.,1&- /1- • % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
r=> If work closes more than 50% of a local access street, or closes any portion of an arterial street,
then a TRAFFIC PLAN IS REQUIRED El Pre -Approved TCP Proposed:
PROJECT ADDRESS: /11 323 E: /nt'ss,:on Ave. PARCEL NUMBER:
APPLICANT'S 30B #: 73 LOCATE TICKET # 414
START DATE: 3--//-20/s ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION: pi4 Le Arf, , , "
q 1 /we iA
-1)
5Aowlae W0,1t — West- b0.44c1 3-5-, oft
SIDEWALK
OTHER
3. ?12°/5
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY:
STATE: ZIP:
PHONE:
FAX: CELL:
CONTRACTOR INFORMATION Si )1 fa e -/v) cost C31e.
NAME: _5 e {rico (or:ca+:0,1
MAILING ADDRESS: ___W ei /V. nOr Ct ft CITY: 5 /Act ii e ‘1,-,i)ey STATE: VJ/). ZIP: 992/6
PHONE: so - S32 - 030 v FAX: 50(1'53-2 65 5 CELL:
CITY BUSINESS LICENSE NO.: 5Er/9 L -1 119 p ci
CONTRACTOR LICENSE NO.: 60 1c c,11 i 1 EXPIRES:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2 :
CONTACT NAME: TM Brefmc
PHONE: ..20t teeye3- 7
R EC E \Tr:
CSV PERMiT CENTER
MAR 0 A 2015 ,
Project
Name V --
Modified April 14, 2014
htto://www.sookanevalley.orgifileggrege/124/938/21J)194.6/1496/2831/ROWPA.dgc
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**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK:Gas
(circle one)
Electric
Water
CATV
Communication
-
Sewer
Other
TYPE OF GUT/REPAIR:
(circle one)
Asphalt
Gravel
_
Concrete
Other
SIZE OF CUT
(width) x (length)
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
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 inures to the property owner. 3) The signatory is the property
owner or has permission to represent the property owner In this transaction. 4) M 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 Vailey 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 30t.
Applicant Signature:
"11/1"1
Date: 3-1.20/r
Method of payment: ❑ Cash ❑ Check ❑ Visa** ❑ Mastercard**
** If paying with credit card, the City will call for credit card Information when the permit is ready to be issued,
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Modified April 14, 2014
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