2015, 08-17 Permit: ROW-2015-0527 ROW i■ •
■
Community Development Department
Permit Center (Staff Use Only)
i■ 11703 East Sprague Avenue, Suite B-3
Spol�ane Spokane
(50 ) Gley, 03 99206 PERMIT NUMBER:
Tel: (509) 668 0036
Valley Fax: (509) 688-0037 PERMIT FEE:
permitcenter@spokanevallev,orq
RIGHT OF WAY (ROW) PERMIT APPLICATION
E APPROACH � PAVEMENT CUT (SEE BELOW) SIDEWALK
Mi CURB & GUTTER LJj WORK THROUGH MANHOLE 1 OTHER
ROAD OBSTRUCTION NO ElYES (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: __,50.0(., .)J u`a/1�rC���Fvl PARCEL NUMBER:
APPLICANT'S JOB #: /51 c Zo/ LOCATE TICKET#
START DATE: l ZO/15 ANTICIPATED COMPLETION DATE: gi3p//s
PROJECT DESCRIPTION-
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PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR INFORMATION
NAME: ea 14-ft"A.1F -r C._ C1
MAILING ADDRESS: (J3 (-3 lye (F, Zt 9CITY: 5 7p fLFt t F STATE: t,(14_, ZIP: C/52,
PHONE: 1 - SO (-T'-'3 / 7 . FAX: 60e) 'a CELL:
CONTRACTOR LICENSE NO.: 5f ie.,4 pe, 9 g Lc,. EXPIRES: V/ 5'/ S CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME: C _N_ C PHONE: ,5C) C{- r 3 2Z
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_Row-Zo15-- 05.2 7
Modified April 14, 2014 Page 1 of 2
http://www.sookanevallev.ora/fiiestorane/124/938/210/948/1496/2831/ROW PA.doc
Received Time Aug. 17. 2015 10: 13AM No, 2278
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK: Gas Electric Water CATV Communication Sewer Other
(circle onel
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/w
be served by potable water. 2) Ownership of this City of Spokane Valley permit Inures to the property owner. 3) The signatory Is the proper
owner or has permission to represent the property owner In this transaction. 4) Ail construction Is to be done In full compliance with the City
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) The City
Spokane Valley permit Is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or addition
Information may be required to be submitted and subsequently approved before this application can be processed.
EXPIRATION
Right-Of-way permits Issued between April 15C and September 30th are valid for 30 days after the date of Issuance, with a one-time 30-da
extension available. Right-of-way permits issued between October 1sb and March 31st are valid until the following April 30th.
%l
Applicant Signature: Lc e� z_- %,(,tet.: -Z.. ..u.._. Daate: j7it-s
Method of payment: ❑ Cash 111Check I4/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 COMPLETI(
•
Modified April 1.4, 2014 Page 2 of 2
htto://www.sDokanevallev rci file_storaaeL]24/9381210/94811496/2831/ROWPA.doc
Received Time Aug. 17. 2015 10: 13AM No. 2278
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Received Time Aug. 17. 2015 10: 13AM No. 2278