2011, 06-13 Permit App: 11001726 ROW, Plumbing FixturesSpokane
Valley
RIGHT OF WAY (ROW) PERMIT APPLICATION
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
Oermitcenter(Tsookanevallev.orci
i
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
Q DRIVEWAY 0 PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
0 CURB & GUTTER 0 OTHER
ROAD OBSTRUCTION nNO
0 YES ***TRAFFIC PLAN REQUIRED
PROJECT ADDRESS: el/0 StWL-, 12i'✓6 v
START DATE: (!j ANTICIPATED'(COMPLETION DATE:
BUILDING OWNER NAME: f
NAME: 41,'/prtvk 7)'
ADDRESS: 2/ 6 E �dw iv, 21 veil -L .14y
CITY:
PHONE:
STATE:
ZIP: /SZI�
FAX:
CELL:
CONTACT NAME:
PHONE:
FAX:
CELL:
CONTRACTOR NAME: 14ci v► C e -A, 1,444
MAILING ADDRESS: te4)16
CITY:
PHONE:
itA
STATE:
L-1
FAX:
CELL:
ZIP: ell O/ 4,
CONTRACTOR LICENSE No.:
TIER:
EXPIRES:
CITY BUSINESS LICENSE NO.:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 10 ARTICLE 2)
SIGNATURE:
DATE:
****MUST BE COMPLETE IF PAVEMENT CUT****
TYPE OF WORK
CONDITION OF CUT
TYPE OF
REPAIR
EXISTING ROAD CONDITION
Gas
Sawcut
Asphalt
Depth of Asphalt:
Electric
Grind
(preapproved only)
Concrete
Depth of Gravel:
Water
CATV
Comm.
CSewe�
Other
Effective October 28, 2007 Page 1 of 2
http://www.spokanevalley.org/filestorage/124/938/210/948/1496/Right_of_Way_(ROW )_Permit_App_1-11-11.doc
Asphalt (width X length)
Concrete (width X length)
Locate Ticket #: '
X
X
X
X
X
X
X
X
X
X
X
X
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 inure 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.
Signature
Date:
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Effective October 28, 2007 Page 2 of 2
http://www.spokaneva I ley.org/filestorage/ 124/938/210/948/1496/Right_of_Way_(ROW )_Permit_App_1-11-11.doc
apoxane
11703 E Sprague Ave, Suite B-3
Spokane Valley, WA 99206
(509)688-0036 FAX: (509)688-0037
permitcenten spokanevaley.org
Community Development
Plumbing Permit ApplicationQi
SITE ADDRESS: 8)1%� C S6ctit►. 2i ✓&C i.
PERMIT NUMBER:
PERMIT FEE:
❑ Commercial ❑ Residential
Building Owner
Name: m . 1 A *7-0,16 Phone: Fax:
Address:
ii 4.I a c mivik ,ttUE2 4104y City State: 144.4 Zip: C.).z.",
Contractor
Name: Phone: .-� }._ /y` `,,� 6-1 Fax:
11 t
't �� J- �J
rr ,� f
Address: ! S 1 / /1 IL E t �0� City: State: , Zip: cyd,C Z _Cc:
14-6"."">
License No: City Business Lic:
Contact/Project Manager:
Name: Phone:
# OF UNITS
PLUMBING FIXTURE ON A TRAP
TOILETS
URINALS
TUBS
SHOWERS (per trap)
SINKS
Lav!Basins, Bar, Floor, Kitchen, Laundry, Utility, Janitor, Photo, X-ray, Food,
Prep/Culinary Meat
DISHWASHER
CLOTHES WASHER
GARBAGE DISPOSAL
WATER SOFTNER
FLOOR DRAIN
Area, Case Coil, Trench, Condensate
ROOF DRAIN/OVERFLOW DRAINS
FOUNTAIN, DRINKING
WATER PIPING/DRAIN-IN WASTE
Installation, Alterations, Repair, Reversals
l
WATER USING DEVICE
Ice and/or Coffee maker, hose bib, steamer proofer, carbonator, swamp cooler
PRIVATE SEWAGE DISPOSAL SYSTEM
WATER HEATER
If Gas, See Mechanical
INDUSTRIAL WASTE PRETREATEMENT
INCEPTORS
Including traps, vents except kitchen type grease interceptors functioning as fixture traps
REPAIR OR ALTERATION
Water piping, drainage or vent pping
ATMOSPHERIC TYPE VACUUM BREAKER
BACK FLOW PROTECTIVE DEVICE
Other than atmospheric type vacuum breakers
MEDICAL GAS
INCEPTORS
❑CASH D CHECK D VISA DMC
Card#
SIGNATURE:
EXPIRES:
VIN:
CURRENT FEES AVAILABLE AT: http:llwww.spokanevallev.orq/ under the quick links for Forms, Master Fee Schedule.
httpJ/www.spokanevalley.org/uploads/Community Developmenteocuments/Forms/Building/PlumbingPermitApptic ation040309.doc