2014, 09-24 Permit App: ROW-2014-0526 ROWSpokane -_
Valley''
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RECEIVED,
Community Development Department
Permit Center er -t 'J !I7�b
11703 East Sprague dbenue; SUite 3
Spokane Valley, WA 99206
Tel:( -5499-)-6 3036 - _0:01 7 20 Lst`�T E
Fax: (509) 688-0037
permitcenterCcilsaokanevallev.orq
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(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
piDRIVEWAY 0 PAVEMENT CUT (SEE BELOW)
CURB & GUTTER NI OTHER
ROAD OBSTRUCTION 64 NO
PROJECT ADDRESS: /p 9ZZ j 714' AuZ LID/no r ‘3"k8 ///0f9
START DATE: /b/L/;c1 ANTICIPATED COMPLETION DATE: Jtl/G//'/
0 SIDEWALK
YES ***TRAFFIC PLAN REQUIRED
BUILDING OWNER NAME:
NAME:
din7R.5i D r dj45HH),t)G 7 L)
ADDRESS: 'JD L.4Y/F Y Al ID BG Gr _3 % /Z
CITY: Pa'//7-c.4.1.,(J
PHONE: 253 8 (/-x.33
CONTACT NAME: 7oEr i91D
PHONE: Z5j 26,q -c/33/
33
STATE: L.l.) i4
FAX:
ZIP: 837 3
CELL: ZS 3 7.3%' 3221•
FAX: CELL:
CONTRACTOR NAME: ?2,7Ezz-e64,(
MAILING ADDRESS: /377 / LV:14 ..51" A BZ
CITY: STATE: I A-
2_Vfht.) le)/L,e!CIL 4J
ZIP:
983 9 a
PHONE: 25'3 2'7/' Z-899 FAX: ZY3 2'/'f? CELL: LS5 2h /- gi 2 '
CONTRACTOR LICENSE No.: Wi r_ 939Ey(/ EXPIRES: �!!!o/ g. CITY BUSINESS LICENSE NO.: / Q/- Jp7Lf, --I V2.
TIER:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 'ARTICLE 2) ,
SIGNATURE: /3"e"71
.01
DATE:
94>0,77
****MUST BE COMPLETE IF PAVEMENT CUT****
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:
Water
CATV
Comm.
Sewer
Other
Effective October 28, 2007 Page 1 of 2
C:\DOcuments and SPffinnc\iwflfll 1\M , rinrttmPntc\Darmire\rih, of CnnLana Warta.. Dr\ut n.,r,ttr..,F.,....+....
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 L<fwlll
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 kl NO compliance with the City of
Spokane Valley Development code. Referenced nelPs are available for review at the City pf Spokane Valley Penni[ 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 requireg$o be submitted and subsequently approved before this application can be processed.
Signature
Lei
Method of payment: 0 Cash 0 Check
Bankcard #:
Date: 21/42 y// it
0 Visa 0 Mastercard
EXP: VIN#:
Authorized Signature:
PLEASE FAX TO CITY OF SPOKANE'�VALLEY (509) 688-0037 UPON COMPLETION
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Effective October 28, 2007 Page 2 of 2
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