2015, 01-12 Permit App: ROW-2015-0012 ROW Yr 12 1 c 10:57a Vietzke 5092440596 p.1
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�■ Community Development Department
Permit Center (Std Use Only)
o���a 11703 East Sprague Avenue,Suite 8-3
Spol�ane Spokane Valley, WA 99206 PERMIT NUMB R:
Tel: (509) 688-0036
Valley Fax: itcen 688-0037 PERMIT FEE:
pax: (5 9) 688-00 anevallev.orq
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RIGHT OF WAY (ROW) PERMIT APPLICATION
❑ APPROACH PAVEMENT CUT (SEE BELOW) ❑ SIDEWALK
0 CURB & GUTTER g WORK THROUGH MANHOLE 0 OTHER
ROAD OBSTRUCTION ❑ NO 1 YES (if yes, complete the following)
• % of street or # lanes that will be obstructs : SOcZ
• Length of time street will be obstructed' 3c
i=:. If work closes more than 50% of a local access street, or c oses any po Flo ofta arterial street,
then a TRAFFIC PLAN IS REQUIRED 0 Pre-Approved TCP Proposed:
PROJECT ADDRESS: 114DI t VAl-1 ./evii- PARCEL NUMBER:
APPLICANT'S JOB #: _ LOCATE TICKET# 1.5-(C.41 START DATE: U. 3- ANTICIPATED COMPLETION DATE: jLjçic
PROJECT DESCRIPTION: �y
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PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME: Co .o..J.� Y (A 4J k,\-3_,, ,
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR I FORMATION
NAME: SiIi \k.kZ X C.-CWW.4-111,C,
MAILING ADDRESS: �,2dLk, C,1426c,.1VLck, cm: A-:;,,,/v..a.-_, \ iS in.f STATE: lAjok ZIP:90100 \
PHONE: l 6 C‘—2-4 1'q( 0 7 FAX: SCt 9'VI 41' a SIC CELL: SIM — I.9 Lf—C N 7
CONTRACTOR LICENSE NO.: V\e T^2eL+ v EXPIRES: 7 201,CITY BUSINESS LICENS NO.:
BOND/INSURANCE CERTIFICATE#(per SVMC Title 10, Article 2):
CONTACTNAME: tAcA(!` �� PHONE:,_1_ 1p
Project # ROW -701c-0012.
. RECEIVED
iiJN4 n�0
17215 I
CSV PERrv1!T CENTER
Modified April 14, 2014i� Page 1 of 2
C:Users\ eena�'s..�rxloa R/I P/1' ria
Received Time Jan. 12, 2015 9: 37AM No, 1401
Jan 12 1%10:57a Vietzke 5092440596 p.2
a
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK: l
circle one Gas Electric Water CATV Communication SewJr Other
•
TYPE OF CUT/REPAIR:
Asphalt Gravel Concrete Other
(circle one)
SIZE OF CUT i
(width)x (length) [ 0 1C3 0
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 d elling,the dwelling is/will
be served by potable water. 2) Ownership of this City of Spokane Valley permit inures to the property owner. 3) Th 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 c mpliance with the City of
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Perm 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 ordinance . 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 1.1 and September 30`' 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 1H and March 30 are valid until the following April 30w.
61( 1
Applicant Signature: Acaz3ek Date: 19 -7CIJ
Method of payment: ❑ Cash D Check 1Visa** ❑ 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
C:\Users\keena n's\Downloa ds\RO W PA.doc
Received Time Jan, 12. 2015 9: 37AM No, 1401