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2016, 05-17 Permit App: ROW-2016-0251 ROW Community Development Department Permit Center (Staff Use Only) CITY OF 11703 East Sprague Avenue, Suite B-3 Spokane Spokane Valley, WA 99206 PERMIT NUMBER: Tel: (509) 688-0036 \1i11ey Fax: itcen688 0037PerPERMIT FEE: ,•••*Va Fax: (509) 6Ca�spokanevalleY.orq RIGHT OF WAY (ROW) PERMIT APPLICATION ID APPROACH El PAVEMENT CUT (SEE BELOW) ❑ SIDEWALK El CURB & GUTTER ❑ WORK THROUGH MANHOLE ka OTHER ROAD OBSTRUCTION El NO Q YES (if yes, complete the following) • % of street or # lanes that will be obstructed: • Length of time street will be obstructed: 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 El Pre-Approved TCP Proposed: mee c.6 PROJECT ADDRESS: 7/pi , ;, 4.teEper7 ,moo / os2 PARCEL NUMBER: APPLICANT'S JOB #: LOCATE TICKET# START DATE: -/? ANTICIPATED COMPLETION DATE: PROJECT DESCRIPTION: OA G 0 6-'44 �) PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE) NAME: c4 „ay LF- / MAILING ADDRESS: CITY: STATE: ZIP: PHONE: f7 k c •— d 3 f t/ FAX: CELL: CONTRACTOR INFORMATION NAME: eRE"T f./,4 t) rPT ,-Aflf) MAILING ADDRESS: J 4'/4) /� � S' CITY: c j/ STATE:ix ZIP: PHONE: y (3— 7 7 7 1 FAX: CELL: CONTRACTOR LICENSE NO.: EXPIRES: CITY BUSINESS LICENSE NO.: BOND/INSURANCE CERTIFICATE# (per SVMC Title 10, Article 2): /1 CONTACT NAME: t,_,..,tkv..t.?ft Pte:-- / 7 - 2 2 RECEIVED CSV PERMIT CENTER AY 1 7 2016 Project# X0(7-2046' G 13-7 Name Submittal# Modified April 14, 2014 Page 1 of 2 C:\Users\pbarclav\Desktop\Customer Information\ROW application.doc **** IF PAVEMENT CUT, COMPLETE THE FOLLOWING **** NATURE OF WORK: Gas Electric Water CATV Communication Sewer 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 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. EXPIRATION Right-of-way permits issued between April 1st 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 1st and March 31st are valid until the following April 30th. 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:\Users\pbarclay\Desktop\Customer Information\ROW application.doc 70 rri . 1 Iv -q 0 n. 2 y 0 r z 'I Z 3 c Z v ni SU W o o 2. �• `4 M -C a 'C a GI 5 :k < -F, \� Km 3 c 03 1`• a '' r1 m © Z. ,t