2006, 09-18 Permit App: 06003740 ROW my or Ir"' a •Permit Center PERMIT NUMBER:c5 714-'
pU� rie 11707 E Sprague Ave, Suite 106 ��
. ,, 0ValleySpokane Valley,WA 99206 PERMIT FEE: 9'01 -'
(509)688-0036 FAX: (509)688-0037
Community Development www.spokanevalley.org
ROW Construction ❑ Driveway ❑ Pavement Cut **(see below)
Permit Application ❑ Sidewalk ❑ Curb & Gutter ither (_,k,
Road Obstruction ❑ No ❑ Yes (traffic control pla . '02"
PROJECT ADDRESS
START DATE ANTICIPATED COMPLETION DATE
Building Owner: Contractor: Se u rest.
Name: LA Name: A- - ? Con fr.0 c_h,fi_ of f'j zt
Address: /.f-4-0,l E 1, y.-&, Address:
City: 5p. � State: (,t/� Zip:Q94 i6 City: State: Zip:
Phone: 99.4/.._ ay,/ Fax: Phone: Fax:
Contact Person Contractor Lic No: Exp Date:
Name:
City Business Lic.No:
Phone:
Tier
Policy
**MUST BE COMPLETE IF PAVEMENT CUT**
Type of Work Condition of Cut 12A- � ?Lew___ u t a4e1 `-"
Gas Sawcut
Electric Grind(pre-approved only) 45r '^D,�„ n
Water Y , //�.(�
CATV � . C
Communications
Sewer
Other
Type of Repair Existing Road Condition
Asphalt Depth of Asphalt
Concrete Depth of Gravel
Asphalt Concrete Locate Ticket#
Width Length Width Length
X X
X X
X X
BOND/INSURANCE CERT # (PER SVMC TITLE 10 ARTICLE 2)
Signature)L (.,e � :� !f. -►.c - Date
Method of Payment:
❑ Cash ❑ Check ❑ Mastercard ❑ VISA
Bankcard#: Expires: VIN#:
Authorized Signature:
Work completed satisfactorily Date
(INSPECTOR)
PLEASE FAX TO CITY OF SPOKANE VALLEY UPON COMPLETION (509)688-0037
REVISED 10/25/05
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