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2013, 08-28 Permit App: ROW-2013-0424 ROW
Community Development Department 6. Permit Center (Staff Use Only) C�TYOF 11703 East Sprague Avenue, Suite B-3 Spokane Spokane Valley,WA 99206 PERMIT(NUMBER: Tel: (509) 688-0036 galley Fax: itcen 688-0037 PERMIT FEE: oermitcentercThsookaneva llev.orq UL-1 Z� RIGHT OF WAY (ROW) PERMIT APPLICATION DRIVEWAY PAVEMENT CUT (SEE BELOW) Q SIDEWALK CURB & GUTTER 1 OTHER ROAD OBSTRUCTION i- NO Q YES ***TRAFFIC PLAN REQUIRED PROJECT ADDRESS: 15-S'lJ e START DATE: ANTICIPATED COMPLEIION DATE: k-)csj-Z cd_ y BUILDING OWNER NAME: f g NAME: AI ADDRESS: CITY: STATE: p PHONE: FAX: t CONTACT NAME: PHONE: FAX: CELL: CONTRACTOR NAME: MAILING ADDRESS: , 7') � /1/9/P,/11(9�)y �Q CITY: ,5 v'Oortn-A..)( /l ( ju STATE: 1,6119 MP: !�J/ OL/ C PHONE: ©) J S 3"S'27 FAX: CELL: CONTRACTOR LICENSE NO.:,jU ct/C ?$1/P$ EXPIRES: CITY BUSINESS LICENSE NO.: TIER: 0 cIiv POLICY: BOND/INSURANC ERTIFICATE #: (PER SVMC TE 10 72pery SIGNATURE: DATE: ****MUST BE COMPLETE IF PAVEMENT CUT**** TYPE OF WORK CONDITION OF CUT TYPE OF EXISTING ROAD CONDITION REPAIR Gas Sawcut Asphalt Depth of Asphalt: Electric Grind Concrete Depth of Gravel: (preapproved only) Water CATV Comm. Sewer Other • Effective October 28, 2007 Page 1 of 2 http://www.spokanevalley.org/filestorage/124/938/210/948/1496/Right_of_Way_(ROW)_Permit_App_1-11-11.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 i a permit or approval for any violation of federal, state or local laws, codes or ordinances. 6) Plans or additional information may be squired o be submitted and subsequently approved before this application can be processed. Signature / Date:,) PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION • • Effective October 28, 2007 Page 2 of 2 http://www.spokanevalley.org/filestorage/124/938/210/948/1496/Right_of Way_(ROW)_Permit_App_1-11-11.doc