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2016, 02-11 Permit App: ROW-2016-0098 Right of WayQTY OF Ime Malley 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(a)spoka neva I lev.oro (Staff Use Only) PERMIT NUMBER: PERMIT FEE: RIGHT OF WAY (ROW) PERMIT APPLICATION APPROACH PAVEMENT CUT (SEE CURB & GUTTER WORK THROUGH MANHOLE E O HERALK ROAD OBSTRUCTION NO YES (if yes, complete the following) �j • % of street or # lanes that will be obstructed: 21 /t • Length of time street will be obstructed: ,,,e c* 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: �(G Y �_ C%,i¢p�PARCEL NUMBER: APPLICANT'S JOB #: LOCATE TICKET # START DATE: 2 ( ANTICIPATED COMPLETION DATE: PROJECT DESCRIPTION: 4 � PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE) NAME: MAILING ADDRESS: CITY: STATE: ZIP: PHONE: FAX: CELL: CON CONTRACTOR LICENSE NO.: CZ_F0LCC q,,,erEXPIRES: -�� - / 7 CITY BUSINESS LICENSE NO.: BOND11NSURANCE CERTIFICATE # (per SVMC Title 10, Article 2): CONTACT NAME: Now -7016 - 00'q ro NE: Modified April 14, 2014 Page 1 of 2 P:\Community Development\11 Forms\B. Development Enoineering\ROWPA.doc **** IF PAVEMENT CUT, COMPLETE THE FOLLOWING **** NATURE OF WORK: circle one Gas Electric Water CAN Communication Sewer Other TYPE OF CUT/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) 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 submitted and subsequently approved before this application can be processed. EXPIRATION Right-of-way permits issued between April l't 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 1st and March 31't are valid until the following April 30tH icant Siqnature: Date: Method of payment: ❑ Cash '-Check ❑ Visa** ❑ Mastercard** I-((_((� ** 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 Page 2 of 2 PACommunity Development\11 Forms\B. Development Engineering\ROWPA.doc