2015, 05-18 Permit App: ROW-2015-0261 ROW ■x05/18/2015 11:09 NAA 5094832525 SPOKANE DITCH AND CABLE -' VALLEY -1---00-1
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Community Development Department
` • Permit Center (Staff Use Only)
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U 11703 East Sprague Avenue,Suite B-3
Spokane Valley,WA 99206
Tel: (509) 688-0036 PERMIT NUMBER:
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Valley Fax: itcen 688-0037 PERMIT FEE:
pax: (5 9) 68 -0037 evallev.orq
RIGHT OF WAY (ROW) PERMIT APPLICATION
ilii APPROACH ,iir! PAVEMENT CUT (SEE BELOW) ilk SIDEWALK
!iiCl' CURB &GUTTER '., WORK THROUGH MANHOLE El OTHER
ROAD OBSTRUCTION El NO jlaYES (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 iIP! Pre-Approved TCP Proposed:
PROJECT ADDRESS: / 12--z__. E p ,,,, t ,,Q„PARCEL NUMBER:
APPLICANT'S JOB #: /..5D,7 10 / 7 LOCATE TICKET#
START DATE: 5/2-o ii s ANTICIPATED COMPLETION DATE: 6/2_g/i
PROJECT DESCRIPTION: 4 ry... ,h 1/4-4_,„24:., .6 ped 44
12- — S b c tA.,,__LI
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: zip:
PHONE: FAX: CELL:
CONTRACTOR INFORMAATION
NAME: Apo K.H-L E Edi-C 1.1...i-k- I. C.,4'11..- f J--IO G-
MAILING ADDRESS: PO 13 0.7( Z.i 9 CITY: S )Q K/ivu STATE: LU - ZIP: 952,i '
PHONE: I - SCS GI-s Lf P'3 117 2- FAX: 605-y'3 -z S ZS CELL:
CONTRACTOR LICENSE NO.: 5 DIC,A bac, lei Lc2. EXPIRES: 3'j S// 5 CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE#(per SVMC Title 10, Article 2):
CONTACT NAME: V( GiL i �L.0 IZ N? --______RHONE. _ ,_co C'/—44,173 /z,---).4.,..
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Modified April 14, 2014 Page 1 of 2
htto://www.sookaneva ilev.orq/filest-orage/124/938/210/948/1496/2831/ROW PA.doc
Received Time May. 18. 2015 7: 48AM No. 1875
05/18/2015 11:09 FAX 5094832525 SPOKANE D11 CH AND CABLE VALLEY L 002
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK.: Gas Electric Water CATV Communication Sewer Other
(circle one)
TYPE OF CUT/REPAIR: Asphalt Gravel Concrete Other
(circle one)
SIZE OF CUT
(width) x (length)
STAFF TO COMPLETE:
ROAD TIERPAVEMENT 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/w1
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 Is to be done In full compliance with the City c
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) The City c
Spokane Valley permit Is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additions
Information may be required to be submitted and subsequently approved before this application can be processed.
EXPIRATION
Right-of-way permits Issued between April 1st and September 30th 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 1st and March 31st are valid until the following April 30th.
Applicant Signature: U/1_11 j Date: 5 /1l iS
Method of payment: ❑ Cash 0 Check $iisa** 0 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 COMPLETI(
Modified April 14, 2014 Page 2 of 2
htto://www.sookanevallev.oro filestoraoe/124[93@L210/948/1496/2831/ROWPA.doc
Received Time /lay. 18. 2015 7:48AM No. 1875
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