2015, 06-04 Permit App: ROW-2015-0317 ROW ti961 '°N AVl :OI SIOZ unr atoll paAia°a�
Community Development Department
Permit Center (Staff Use Only)
cnY� 11703 East Sprague Avenue, Suite B-3
SFikane Spokane Valley, WA 99206 PERMIT NUMBER:
Tel: (509)688-0036
4,jj T���ey� Fax (509)688-0037 PERMIT FEE:
�d Fax: center@sookanevallev.arq
RIGHT OF WAY (ROW) PERMIT APPLICATION
;II!h APPROACH PAVEMENT CUT (SEE BELOW) l" SIDEWALK
IF CURB & GUTTER Ej WORK THROUGH MANHOLE ! `, OTHER
ROAD OBSTRUCTIONNO iii YES (if yes, complete the following)
\ • % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
E=> 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: / 530 /ZGc..«� PARCEL NUMBER:
APPLICANT'S JOB #: / 57 D '1.57 U LOCATE TICKET#
START DATE: Co /7 S ANTICIPATED COMPLETION DATE: (o%VfS
PROJECT DESCRIPTION:
J2 /536 £
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTRACTOR INFORMATION
NAME: o Ce
MAILING ADDRESS: 100 V3 ( , z..( 9 CITY: 5e o K«-a/. STATE: I /4 ZIP: q9-2,1 7
PHONE: . I - So 9— (4?-SFAX: 60 ) t/si 3 "Z 7rs CELL:
CONTRACTOR LICENSE NO.: 5f0 IL,q.WO ctq LLs EXPIRES: g/j 5// 5 CITY BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE# (per Title 10,Article 2):
•
CONTACT NAME: JJ C.4_I GC N F•r(2 . PHONE: ,SU C}-4-/y. a..7
7--RECEIVED I
CSV.PERMIT CENTER
AIN 0 3 .2015
Project# Note-20/r-U3/?
Name 712,g '
Submittal #
Modified April 14, 2014 Page 1 of 2
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**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK: Gas Electric Water CATV Communication Sewer Other
circle onel
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/w
be served by potable water, 2)Ownership of this City of Spokane Valley permit Inures to the property owner. 3) The signatory Is the proper(
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,
Spokane Valley Development code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) The City
Spokane Valley permit is not a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or addition,
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-da
extension available. Right-of-way permits issued between October 1st and March 313t are valid until the following April 30th
Applicant Signature: G ..:ec �G� z•� .. . Date: 3/
Method of payment: ❑ Cash ❑ Check Tisa** ❑ 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 COMPLETIC
Modified April 14, 2014 Page 2 of.2
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Received Time Jun. 3. 2015 10: 21AM No. 1964 `