2016, 03-08 Permit App: ROW-2016-0091 ROW • Ui-UO- io, UL I7r Nl,
■ ■
■
■ ■ Community Development Department
■�l, Permit Center (Staff Use Only)
■� crrx of 11703 East Sprague Avenue,Suite B-3
■ �c Spokane Valley, WA 99206 PERMIT NUMBER:
�V11L✓Lfl� Tel: (509) 686-0036
Valley Fax: (509) 688-0037 PERMIT FEE:
permitCenterC<ilsDOkal]evalley,orq
RIGHT OE WAY (ROW) PERMIT APPLICATION
❑ APPROACH R PAVEMENT CUT (SEE BELOW) [] SIDEWALK
❑ CURB & GUTTER ❑ WORK THROUGH MANHOLE El OTHER
ROAD OBSTRUCTION Dr-NO ❑ YES (If yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
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.3 -5 • F,E , _s PARCEL NUMBER:
APPLICANT'S JOB #: LOCATE TICKET#
START DATE: ANTICIPATED COMPLETION DATE: __3//o//4.
PROJECT DESCRIPTION:
/1'l A 7v ,'El` rq(,
PROPERTY OR BUILDING OWNER INFORMATION (XP APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR INFORMATION
NAME:VERA WATER&POWER
MAILING ADDRESS: PO Box 630 CITY: SPOKANE VALL STATE:WA ZIP: 99037
PHONE:(509)924-3800 FAX: (509)922-3929 CELL:
CONTRACTOR LICENSE NO.: EXPIRES: CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE# (per SVMC Title 10, Article 2);
CONTACT NAME:TODD HARMON PHONE: 509 924-3800
Retia zcl6 - R
Modified April 14, 2014 Page 1 of 2
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Received Time Mar. 8. 2016 2: 08PM No. 3041
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**** IF PAVEMENT CUT, COMPLETE THE FALLOWING ****
NATURE OF WORK: Gas Electric Water CATV Communication Sewer Other
(circle one) _ _
TYPE OF CUT/REPAIR: rAsph It Gravel Concrete Other
(circle one)
SIZE OF CUT ' / GG
(width) x (length) `/ )( f✓
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
P-ISCLAIMER,
The permitted verifies, acknowledges and agrees by their signature that: 1) if this permit is for construction or on a dwelling,the dwelling I5/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 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.
EXPXRATXON
Right-of-way permits Issued between April 1" and September 30`^ 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 1"and March 31"are valid until the following April 30",
Applicant Si nature----- � "
9 Date0 � �,�
Method of payment: El 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:\U$ers\tharmon.vERAwP\Documents\Spokane Vey R0WEA4oc
Received Time Mar, 8. 2016 2: 08PM No. 3041