2015, 06-01 Permit App: ROW-2015-0303 ROW006/01/2015 10:40 FAX 5094832525
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SPOKANE DITCH AND CABLE � VALLEY U 001/003
Community Development Department
Permit Center (Staff Use Only)
11703 East Sprague Avenue, Sulte B-3
Spokane Valley, WA 99206 PERMIT NUMBER:
Tel: (509) 688-0036
Fax: (509) 688-0037 PERMIT FEE:
permltcenter(&sookanevallev org
RIGHT OF WAY (ROW) PERMIT APPLICATION
sa APPROACH ® PAVEMENT CUT (SEE BELOW) im SIDEWALK
BE CURB & GUTTER WORK THROUGH MANHOLE V OTHER
ROAD OBSTRUCTION +` NO N1 YES (if yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
b 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 00 Pre -Approved TCP Proposed:
PROJECT ADDRESS: 11102- E PARCEL NUMBER:
START DATE: relgll S ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION:
0 7
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL.-
CONTRACTOR
ELL:
CONTRACTOR INFORMATION
MAILING ADDRESS: PQ rly (e Z,I 9 CITY: 5 #20 K tiv e STATE: ZIP' -
PHONE: I " S 0 `l r—F P 3 I Z.%FAX: ➢�J—LI b' S' ZS CELL:
CONTRACTOR LICENSE NO.: SQOKAR bC0 7Cl Le. EXPIRES: 3-11:5115 CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME: ( ) I C_Ll—I I U_1-Z—N-E-he _ PHONE: .Sn 9 —
RECEIVED
CSV PERMIT CENTER
JUN 01 2015
Project# Rw. I^ oV5
Name
Modlfled Aprll 14, 2014 Page 1 of 2
htto•//www sc)okanevallev ora/`filestorage/124/938/210/948/1496/ 831/ROWPA do
Received Time Jun. 1, 2015 7:18AM No, 1948
06/01/2015 10:40 FAX 5094832525 SPOKANE DITCH AND CABLE � VALLEY
**** IF PAVEMENT CUT COMPLETE THE FOLLOWING ****
ID002/003
NATURE OF WORK: I Gas I Electric Water CAN Communication Sewer Other
(circle one)
TYPE (circle onCUT/e) PAIR: I Asphalt I Gravel Concrete Other
SIZE OF CUT
STAFF TO COMPLETE:
ROAD TIER;
PAVEMENT CUT POLICY APPLIES?
DISCLAIMER
The permitted verifles, acknowledges and agrees by their signature that: 1) If this permit Is for construction or an a dwelling, the dwelling Is/w
be served by potable water. 2) Ownership of this City of Spokane Valley permit Inures to the property owner. 3) The signatory is the propert
owner or has permission to represent the property owner In this transaction. 4) All construction I.s to be done In full compliance with the City,
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) The City <
Spokane Valley permit Is not a permit or approval for any violation of federal, state or local laws, codes or ordinances, 6) Plans or addition
Information may be required to be submitted and subsequently approved before this application can be processed.
€XPIRATION
Right-of-way permits Issued between April 1" and September 30v are valid for 30 days after the date of Issuance, with a one-time 30 -da
extension available. Right-of-way permits Issued between October I" and March 31" are valid until the following April 301h.
Signature:
Date! /n
S
Method of payment: ❑ Cash ❑ Check I�/Isa** ❑ Mastercard**
** If paying with credit card, the City will call for credit card Inforrm-atlon when the permit Is ready to be Issued.
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETIC
April 14,
http•//www sookanevallev grg/file r /124Zgj8l2lo/94811496Z2Q3 OWPA do
Received Time Jun, 1, 2015 1:18AM No. 1948
Page 2 of 2
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RECEIVED
CSV PERMIT CENTER
JU€2 91 2915
Project # '�Dv-20/S. 603
Name
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