2005, 11-29 Permit App: 05004496 ROW0•1#1\.,,
Splkane
4.00Valley
Call 24 hours before inspection required
Phone 509.688-0195 Fax 509.688-0037
DEPARTMENT OF PUBLIC WORKS
Anticipated start date
Permit #
ROW CONSTRUCTION PERMIT
Location of property ave././� : Ui i vE C 145-/..3-3 / 707 )
(Address/Parcel #, if available)
Applicant Name LqiA),'2„Nr-.-,i r`ts c.c� Fax
/Jig L) sfroec, GJrt •
Address /2'/t £ G1%/v y(pv. n3c '!r2/ Phone q- '"7t)-
Contractor's Name / "JJ C 0724 e-arliWt• iJeep
Address /I'e'
Contractor's Re .# /✓J - C a ` )A'3
Phone
Expires $J' �✓ (moi
PROJECT DESCRIPTION (Provide site sketch or plan as necessary for clarity)
Sewer Connection
EllDriveway
Es Curb & Gutter El Gas Installation/Repair
111 Cable/Conduit/Pole Sidewalk Repair/Construction
Water Installation/Repair 0 Other
Pavement Cut Dimensions
Bond/insurance certification must be on file with the City. Bond #
SPECIAL CONDITIONS:
Permittee Signature Approved
Date
I hereby authorize the City of Spokane Valley to charge the fee for this permit to my credit card.
Card # Expiration Date
Name of Holder Signature
Fees Paid$
(Application) (Inspection)
In addition to the permit application fee of $16.00 (utility) or $25.00 (construction), inspection on
each permit will be billed to the permittee at a rate of $50.00 per hour with a $25.00 (1/2 hour)
minimum. Permittee signature constitutes an agreement to these terms and provisions.
Work completed satisfactorily (Signed) Date
Date Init
Permit not valid until One -Call Notification Ticket # entered here
PERMIT MUST BE KEPT ON SITE