2014, 10-30 Permit App: ROW-2014-0634 Sewer/ROWt 3U 14 U /:13p VletzKe 5UyL44UDyq P.
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Community Development Depa
Permit Center EPvRmFEE-'ff_
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CITYSpWhne
11703 East Sprague Avenue, Su Wllr3� Spokane Valley, WA 99206 CC.• R:
Tel: (509) 688-0036
Fax: (509) 688-0037 R M I T C
Va1ley� permitcenter(laspokanevalley.orqNTFR
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RIGHT OF WAY (ROW) PERMIT APPLICATION
❑ APPROACH ❑ PAVEMENT CUT (SEE BELOW) ❑ SIDEWALK
❑ CURB & GUTTER ❑ WORK THROUGH MANHOLE '� OTHER
ROAD OBSTRUCTION NO ❑ YES (if yes, complete the following)
% of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
c* 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: R � '� I C � . 2_S_01.PARCEL NUMBER: Lf r2 r% -]/r
, 0 V-6
START DATE: C?C._ v- ANTICIPATED COMPLETION DATE: CK 4- d 20y
PROJECT DESCRIPTION: h.r
W\OLL(& 14,0 F �y � �j5 U10
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PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME: [ -i J I \4e 116.0 lr,
MAILING ADDRESS: LO t3 N Y° i e VC. e- CITY: 5-'0$ o� VM['1by STATE: `ii4_;j ZIP: C7P(121b
PHONE. FAX: CELL:
CONTR'A'CTOR INFORMATION
NAME V 'I e�V-R_ K—= )' C CkVA J'q p
MAILING ADDRESS:
'S' F��J �/l C � CITY: 0,-2
� (�._, / STATE: `J� p ZI(PP:(�� (�/
PHONE:-�r(�l`� "'�UO% AX: �O "l^Z-I ��0-% )tELL: 56-1 ��-1 ` {p,
CONTRACTOR LICENSE NO.: k I tC�2-'e-(—
BUSINESS LICENSE NO.:
BOND/INSURANCE CERTIFICATE # (per SVIMC Title 10, Article 2):
CONTACT NAME: = V� PHONE: 0 9 — ! ! ce --6-?C 7
Modified April 14, 2014 Page 1 of 2
PACommunity Development\11 Forms\B. Development Engineering\ROWPA.doc
Received Time Oct.30. 2014 6:39PM No -1187
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Oct 30 14 01:13p V letzke
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OWJZ441-10�jo p./-
**** IF PAVEMENT CUT. COMPLETE THE FOLLOWING ****
NATURE OF WORK:
Gas Electric
Water
CATV
Communication I Sewer
Other
circle one
r
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.
EXPO TWO N
Right-of-way permits issued between April I" and September 301 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 1't and March 31" are valid until the following April 30th.
cant Signature: 0 -
Date: /G,
Method of payment: ❑ Cash ❑ Check Visa** ❑ Mastercard**
** if paying with credit card, the City will call for credit card inormation when the permit is ready to be issued.
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Modified April 14, 2014
P•\Community Development\11 Forms\6 Development Eneineering\ROWPA.doc
Received Time Oct.30, 2014 6:39PM No,1187
Page 2 of 2
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