2013, 07-10 Permit App: ROW-2013-0346 Pavement CutCommunity Development Department P.0ty -'Zo13 —d3416
Permit Center (Staff Use Only)
11703 East Sprague Avenue, Suite B-3
Spokane Spokane Valley, WA 99206 PERMIT NUMBER:
Tel: (509) 688-0036 /
Wley- Fax: (509) 688-0037 PERMIT FEE: 1W 6 44S,0O
Perm itcenterCsbspokanevaIley.or4
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RIGHT OF WAY (ROW) PERMIT APPLICATION
DRIVEWAY `PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
CURB & GUTTER OTHER
ROAD OBSTRUCTION NO YES ***TRAFFIC PLAN REQUIRED
PROJECT ADDRESS: s + c $ AI / '% iei DI
START DATE: 7 - 1 E — J_3 ANTICIPATED COMPLETION DATE:
BUILDING OWNER NAME: t �-� y V\'n' I- 0m 2 f
NAME:
ADDRESS:
CITY: STATE: ZIP:
PHONE: FAX: CELL:
CONTACT NAME:
PHONE: FAX: CELL:
CONTRACTOR NAME: UO ryl 1, r
MAILING ADDRESS: P, V , 13 Cay 4
CITY: ! V Q_ k -J Vh
0, L% _ I � 0.-
/
PHONE: � ()9 L1i � f Q ` (eft w
CONTRACTOR LICENSE NO.: W mw =0
TIER: 935 LA
POLICY:
(� /��jScITATE:: / Li
FAX' o f - "c" (3 q _ 6(b
01 1 EXPIRES: 'i _3 q
013
os
ZIP: /
CELL'
CITY BUSINESS LICENSE NO.: G 0
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 10 ARTICLE 2)
SIGNATURE:, e,_ �..� DATE: 72 ho
****MUST BE COMPLETE IF PAVEMENT CUT****
p.? 7$ �
TYPE OF WORK
CONDITION OF CUT
TYPE OF
REPAIR
EXISTING ROAD CONDITION
Gas
Sawcut
Asphalt
Depth of Asphalt:
Electric
Grind
(preapproved only)
Concrete
Depth of Gravel: c I
Water
CATV
Comm.
Sewer
Other
Effective October 28, 2007 Page 1 of 2
P:\Community Development\11 Forms\B. Development Engineering\ROWPA.doc
Asphalt (width X length)
Concrete (width X length)
Locate Ticket #:
X
X
X
X
X
X
X
X
X
X
X
X
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 inure 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.
Signature Date:
Method of payment: ❑ Cash ❑ Check Visa ❑ Mastercard
Bankcard #: EXP: VIN#:
Authorized Signature:
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Effective October 28, 2007 Page 2 of 2
P:\Community Development\11 Forms\B. Development Engineering\ROWPA.doc
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