2015, 05-20 Permit App: ROW-2015-0274 Water Service Repair•
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Spokane
Valley
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcentersookar e_valley•or9
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY ROW PERMIT APPLICATION
❑ APPROACH Lr PAVEMENT CUT (SEE BELOW)
❑ CURB & GUTTER ❑ WORK THROUGH MANHOLE
ROAD OBSTRUCTION ❑' NO ❑ YES (if yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
E SIDEWALK
❑ OTHER
q 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:
/(Z 1 S S? C_P ACC.6S PARCEL NUMBER:
APPLICANT'S 3013
START DATE: S
PROJECT DESCRI'TI
S
N: �n^
LOCATE TICKET #
ANTICIPATED COMPLETION DATE: 5
4111111111011,
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS:
CITY:
STATE: ZIP:
PHONE;
FAX: CELL:
CONTRACTOR INFORMATION
NAME: VERA WATER & POWER
MAILING ADDRESS: PO Box 630
czre: SPOKANE VALL STATE: WA zip: 99037
PHONE: (509)924-3800 FAX: (509)922-3929
CELL:
CONTRACTOR LICENSE NO.: EXPIRES: CM BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2);
CONTACT NAME: TODD HARMON
PHONE: (509)924-3800
Modified April 14, 2014 Page 1 of 2
C:\User,ttharmon VERAWP\Docurr 91s\Spokane Valley ROWPA doc
Received Time May.20. 2015 9:59AM No.1895
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**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK:
(circle one)
Gas
Electrics
CATV
Communication
Sewer
Other
TYPE OF CUT/REPAIR:
(circle one)
CAsphalt
Gravel
Concrete
Other
SIZE OF CUT
width x len•th
tO � — (Z-'
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
DISC) AIMEf
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 nota 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 AprII 10 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 15' and March 31" are valid until the following April 30`".
Applicant Signature: Date:
Method of payment: ❑ Cash ❑ Check ❑ Visa** ❑ 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
Modified April 14, 2014 Page 2 of 2
C: Us -r VERAWP Do ..)(ane Valley ROWPf,.doc
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Received Time May, 20. 2015 9:59AM No. 1895
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