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2006, 05-19 Permit App: 06001925 ROW Obstruction _ Permit Center Spokane 11707 E Sprague Ave, Suite 106 PERMIT NUMBER/ 7C'� ,�,.•''�Valle (70o91768e8Valley8-0036 ,FAXWA: (5097E68.8-0037 9920PERMIT FEE: (5 Community Development www.spokanevalley.org.corn ROW Construction o Driveway o Pavement Cut **(see below) Permit Application ❑ Sidewalk o Curb & Gutter o Other Road Obstruction ❑ No o Yes (traffic control plan required) PROJECT ADDRESS Z—/ � START DATE ANTICIPATED COMPLETION DATE Applicant Contractor , Name: ,Q,? eig % CA 19"a'�/;��; Address: (Z, 717 s q� !�'vUi Address:s�� © ,y '_i% i� City: S60l9Jip, 41.4® ip: z`f Ic y. i i Phone: Fa Phone: �� Contacts Person; ,.. Lic No: , � Exp.Date: Z d Name: City Business Lic No: 47' •-/ Phone Tier Policy **MUST BE COMPLETE IF PAVEMENT CUT** Type of Work Condition of Cut Gas Sawcut Electric Grind(pre-approved only) _ Water iJ CATV 1 Communications '�� Sewer Other Type of Repair Existing Road Condition Asphalt Depth of Asphalt Concrete Depth of Gravel Asphalt Concrete Width Length Width Length X X X X X X X X BOND/INSURANCE CERT # (PER SVMC TITLE 10 ARTICLE 2) Signature Date Method of Payment: (Faxed permit applications will only be accepted with major bankcard) 0 Cash 0 Check 0 Mastercard 0 VISA ❑ Other Bankcard#: Expires: VIN#: Authorized Signature: Work completed satisfactorily Date (INSPECTOR) PLEASE FAX TO CITY OF SPOKANE VALLEY UPON COMPLETION (509)688-0037 REVISED 10125105