2014, 11-07 Permit App: ROW-2014-0644 ROW 11/06/2014 17:57 FAX 5094832525 SPOKANE DITCH AND CABLE - VALLEY Ij001
Community Development Department
Permit Center (Staff Use Only)
11703 East Sprague Avenue,Suite B-3
Spokane Valley,WA 99206
p�e Tel: (509)688-0036 PERMIT NUMBER:
Valley® Fax: (509) 688-0037 PERMIT FEE:
permitcenter@sookanevallev.orct
RIGHT OF WAY (ROW) PERMIT APPLICATION
sl!il APPROACH ilIii PAVEMENT CUT (SEE BELOW) it SIDEWALK
CURB &GUTTER .1, WORK THROUGH MANHOLE OTHER
ROAD OBSTRUCTION NO ilal 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 Pre-Approved TCP Proposed:
PROJECT ADDRESS: 0.62. IU 5 w�gx RPARCEL NUMBER:
APPLICANT'S JOB #: /�FZa(o 16,5 LOCATE TICKET#
START DATE: ////o ANTICIPATED COMPLETION DATE: /j .Ti/ y
PROJECT DESCRIPTION:
`, a�-�e JL ULLL L (��-� urs -e u-�e- ? d
a ,c -a-d OCA
St c 3 L
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR INFORMATION
NAME: ' SeOKAi.3FT1'CC. &- ' C ''(5L.f1171—A3C..
MAILING ADDRESS: Po 13 1 ', z,.i 9 CITY: S o K/ter STATE: W,_ ZIP: C?��Z/ 7
PHONE: I - /" FAX: f5O') e-/S)3 --Z S -S CELL:
CONTRACTOR LICENSE NO.: WOKAbe&`ig LC. EXPIRES: 3// 5// 5 CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE# (per SVMC Title 10,Article 2):
CONTACT NAME: ()( G. i I,C t2 IU E J(Z--. PHONE: 5o 9 41,73 !z
Proect Rosi/_ zol4_o6¢lf
RECEIVED
U 7 2014
Modified April 14, 2014 CSV PERMIT C E N T ENage 1 of 2
htto://www.sooka nevallev.ora/filestoraac/124/938/210/948/1496/2831JROW pA.doc
Received Time Nov, 6. 2014 2: 33PM No. 1222
SUB # t 1 REV. I __�
11/06/2014 17:57 FAX 5094832525 SPOKANE DITCH AND CABLE -> VALLEY Il002
**** IF PAVEMENT CUT. COMPLETE THE FOLLOWING ****
NATURE OF WORK: Gas I Electric Water CAN Communication Sewer I Other
(circle one)
TYPE OF CUT/REPAIR: Asphalt Gravel Concrete Other
(circle one)
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 clone 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
may be required to be submitted and subsequently approved before this application an be proces edances. 6) Plans or additional
e or local laws,codes or
information
EXPIRATION
Right-of-way permits Issued between April lst and September 30th are valid for 30 days after the date of issuance, with a one-time 30 ay
extension available. Right-of-way permits Issued between October 11t and March 31g are valid until the following April 30m.
Applicant G�.��,� �- ///6$Date: //� �cf
PP Signature:
Method of payment: 0 Cash ❑ Check /isa** 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 COMPLETION
Page 2 of 2
Modified April 14,2014
htto://www.sooka neva IIev.ora/fi lestoraael124/938/210/948/1496/2831/ROW PA.doc
Received Time Nov. 6. 2014 2: 33PM No. 1222
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