2014, 10-06 Permit App: ROW-2014-0553 ROW Community Development Department
Permit Center c (Staff Use Only)
_ �s� 11703 East Sprague Avenue, Suite B-3
S OF
Ukane Spokane Valley, WA 99206 PERMIT NUMBER:
Tel: (509) 688-0036
Valleye Fax: (509) 688 0037 PERMIT FEE
permitcenter spokanevalley.orq
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RIGHT OF WAY (ROW) PERMIT APPLICFFINI V E D
8 APPROACH PAVEMENT CUT (SEE BELOW) 0 6 -, LI WALK e
CURB & GUTTER 0 WORK THROUGH MANHOLE 0 HER
ROAD OBSTRUCTION C] NO 'Vs YES (if yes, complete the follolnr*PERM1T CENTER
• oh
of street or # lanes ti-@ ill ct
• Length of time street wilt'I e�offs
1=> If work closes more than 50% of a local access street, or closes any portio of an arterial street,
then a TRAFFIC PLAN IS REQUIRED El Pre-Approved TCP Proposed:
PROJECT ADDRESS: PARCEL NUMBER:
APPLICANT'S JOB #: LOCATE TICKET#
START DATE: ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION:
PROPERTY 01,BUILDI G OWNER INFORMATION (IF APPLICABLE)
NAME: Pe.4 17y a 5 6
MAILING ADDRESS: 7 // 9 //)CITY: 6�d /A '-y STATE: 0//ii ZIP: 9 fp?/62-
PHONE: g g O O2 FAX: CELL:
CONTRACTOR INFORMATION „ /
NAME: .1'°) r r J 1/ /( C Il P.--s,--- LG �/Gr 77j 1"<
MAILING ADDRESS: ' /(1 7 F K /(e cITY:ve /lex'y( ( f y STATE: K�/I ZIP: 9'97 /2
PHONE: 9„2. 6- - / C�C 7 QyFAX: �, -.5-- /C CELL: 7/f -5-7/
CONTRACTOR LICENSE NO.:14.1"I'y�Ni�v/gl�RI/ EXPIRES: CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE# (per SVMC Title 10, Article 2):
CONTACT NAME: rs---2A1.17 /1<t O (`�,f-- PHONE: .76.'8 _ r 7�--?,,,
Modified April 14,2014 Page 1 of 2
http://www.sookanevallev.oro/filestorage/124/938/210/948/1496/2831/ROW PA.doc
**** IF PAVEMENT CUT, COMPLETEJHE, 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 lst 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
htto://www.sookanevallev.ord/filestorage/124/938/210/948/1496/2831/ROW PA.doc