2015, 03-31 Permit App: ROW-2015-0142 ROW Community Development Department
Permit Center (Staff Use Only)
11703 East Sprague Avenue, Suite B-3
CITY OF Spolia.ne Spokane Valley, WA 99206
Tel: (509) 688-0850
66 1-- 720-$-2.V0 PERMIT NUMBER:
40011001Valle3 Fax: (509)688-0037
permitcenter@sookanevalley.orq PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
DRIVEWAY 0 PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
0 CURB & GUTTER 0 OTHER
ROAD OBSTRUCTION Li NO ri YES ***TRAFFIC PLAN REQUIRED
PROJECT ADDRESS: /9Z1)V vb
START DATE: V/i/i 5- ANTICIPATED COMPLETION DATE:
BUILDING OWNER OWNER NAME:
NAME: &mens 7 19r- A.)/E:51--//a)
ADDRESS: PL
4-V /2
ra,Y4L.L.L.IP STATE: t-13 I ZIP: Q2-3 7 3
PHONE: 25-3 ee 4,(7-4/5 FAX: CELL: P33 -73 5269
CONTACT NAME: 1710
PHONE: 25 2 'L' L .- V5.5 1 FAX: CELL:
CONTRACTOR NAME: .1&77,---2.74.wt Z.-.Z.
/4/4-01e 672.Se
MAILING ADDRESS: /.5 70/ e si.t4 E h z--,
Crrt: STATE: L.4)4. ZIP: 9f3 y‘z)
PHONE: Z$ eft,r---2,e1' FAX:.6',5-3 1 CELL: 25-5 2 /--(„:1 2
CONTRACTOR LICENSE NO. nt)e-1"1 1.51eta EXPIRES: 41//3- CITY BUSINESS LICENSE NO.:ZaD/44/14,
TIER:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TIT e TICLE 2)
SIGNATURE: / d)1/4>- 6-46-k DATE: L.,
1.0 E-Obih ...Ad E. Ti- eAAA.d.a411
•
( ***MUST BE COMPLETE IF PAVEMENT CUT****
TYPE OF
TYPE OF WORK CONDITION OF CUT EXISTING ROAD CONDITION
REPAIR
Gas Sawcut Asphalt Depth of Asphalt:
Grind
Electric (preapproved only) Concrete DephofGraeL
Water PtTiVIT CtINTEr?
CATV
Comm. MAR 3 1 2(115
Sewer ,Proper _K0_14."--10/ 4 2-
Other i Nary? 77 V
I Subrntia: '
Effective October 28, 2007 Page 1 of 2
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 •, Itted and subsequently approved before this application can be processed.
Signature f / 5e1-6--GC-11C- Date: // \
Method of payment -13 Cash Check ❑ Visa ❑ Mastercard
Bankcard #: EX,P: VIN#:
Authorized Signature
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
.T-d. 6,X-7/ 3
6_)E'"" T 0 73 7— 44 h1Z 6F /020 2-LAD
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Effective October 28, 2007 Page 2 of 2
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