2007, 10-17 Permit App: 07004181 ROW, Sewer ® � Permit Center i c/
Sj kane 11707 E Sprague Ave, Suite 106 PERMIT NUMBER: -} ?5
,mss Valle Spokane Valley,WA 99206 PERMIT FEE: ()S--
(509)688-0036 FAX: (509)688-0037
Community Development www.spokanevalley.org.com
ROW Construction o Driveway ❑ Pavement Cut **(see below)
Permit Application o Sidewalk o Curb & Gutter o Other
Road Obstruction ❑ No o Yes (traffic control plan required)
PROJECT ADDRESS / Vfa( 11 �6-'1.
START DATE /2 / - 7 ANTICIPATED COMPLETION DATE
Applicain#° r {
Name: 131-, G.,z f•i/'.--,-1 Name: (,r/i G fr
Address: /4(4106 II" Address: /it e 7
City: �r r�'��`... L,c.//„./ Zip: G 9'$ Z14 City: `�%%:�/��..____ it'/../Zip: 71 2 I
Phone: % Fax: Phone: "i -• '( Fax:
COjll111C11 P Sbn ``..` f . * Lic No:1,4/,c/T-c c/ 9i2Exp.Date:
Name: City Business Lic No:
Phone Tier
Policy
**MUST BE COMPLETE IF PAVEMENT CUT**
Type of Work Condition of Cut
Gas Sawcut
Electric Grind(pre-approved only)
Water
CATV
Communications
c�Sewer_j
Ot`fiEi
Type of Repair Existing Road Condition
Asphalt Depth of Asphalt
Concrete Depth of Gravel
Asphalt Concrete
Width Length Width Length
X X
X X
X X
X X
BOND/INSURANCE CERT # (PER SVMC TITLE 10 ARTICLE 2)
Signature-,-- Date / -
Method of Payment: (Faxed permit applications will only be accepted with major bankcard)
❑ Cash ,E1 Check 0 Mastercard 0 VISA 0 Other
Bankcard#: Expires: VIN#:
Authorized Signature:
Work completed satisfactorily Date
(INSPECTOR)
PLEASE FAX TO CITY OF SPOKANE VALLEY UPON COMPLETION (509)688-0037
REVISED 10125105