2015, 06-01 Permit App: ROW-2015-0307 ROW▪ U6/U1/LUIa lb:bl VAN oU9483ZbZo
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Spokane
galley.
SPOKANE DITCH AND CABLE -> VALLEY 1j001/003
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
Qermltcenterftspokanevalley,orq
i
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
ill! APPROACH ®' PAVEMENT CUT (SEE BELOW)
CURB & GUTTER `}' WORK THROUGH MANHOLE
ROAD OBSTRUCTION NO
•
•
SIDEWALK
OTHER
YES (if yes, complete the following)
0/0 of street or # lanes that will be obstructed:
Length of time street will be obstructed:
b 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: d/9O A 7 ac,__.(_ PARCEL NUMBER:
APPLICANT'S JOB #: / S / J 33/ S LOCATE TICKET #
START DATE: ‘'/ 3/, 5 ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION:
t%t=c-P- 6 x"- A__.yrz- y90 a_
E G1 c� u e_ ` f t -H 1 /LA,1140 a Ca._ Rek
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PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP•
PHONE:
FAX: CELL:
CONTRACTOR INFORMATION
NAME: :5 !O le,/j- i.?f ITC t{" ' C.'4-13Lf t
MAILING ADDRESS: PG 8 (� Z( 9 CITY:
PHONE: 1 _SCD /— 4 -14Y -
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STATE: l4,),4-- ZIP: l' /Z / J
FAX:y 3 CELL:
CONTRACTOR LICENSE NO.: 5e0K, 4 WO 9e LC. EXPIRES: 4J/ S // S CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME:
Modified April 14, 2014
http://www. sookanevallev.org/filestorage/124 38/210 948 1496/2831/ROWPA.4oc
Received Time Jun, 1. 2015 12:29FM No. 1953
r2_ PHONE:
rvE
CSV PERMIT CENTER
JUN 01 2015
Project # 1L
Name 117,
Submittal
5 -09—t -/Y3 J a -
Page 1 of 2
SPOKANE 1ITCH AND CABLE -s VALLEY
**** IF PAVEMENT CUT. COMPLETE THE FOLLOWING ****
NATURE OF WORK:
(circle one}
TYPE OF CUT/REPAIR:
circle one
SIZE OF CUT
(width) x (length)
Gas I Electric I Water
Asphalt Gravel
02/003
CATV Communication I Sewer I Other
Concrete I Other
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
pISCLAIMER
The permitted venues, acknowledges and agrees by their signature that: 1) IP this permit Is For construction or on a dwelling, the dwelling Is/wil
be served by potable water. 2) Ownership of this City of Spokane Valley permit Inures to the property owner. 3) The signatory Is the propert)
owner or has permission to represent the property owner In this transaction. 4) All construction Is to be done In Nil compliance with the City of
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Penult Center. 5) The City al
Spokane Valley permit Is not a permit or approval for any violation of federal, state or local Taws, 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 1" 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 1e and March 31` are valid until the following April 30th,
Applicant Signature: LC.Qc,sj
Date: (o%4$
Method of payment: 0 Cash ❑ Check I.SIsa** 0 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 COMPLETIO"
Modified April 14, 2014
MW //www.sookanevallev.om/fllestoraae/124/938/210/948/1495/jr91/ROWPA,dnr
Received Time Jun. 1. 2015 12:29PM No. 1953
Page 2 of 2
06/01/2015 15:51 FAX 5094832525
SPOKANE DITCH AND CABLE + VALLEY
2N003/003
Received Time -Jun: 1. 2015-:12:29PM No. 1953