2014, 08-05 Permit App ROW-2014-0395 ObstructionSpokane
Valley
Community Development Department
Permit Center
11703 East S;ragueV,venue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
perm itcenter@sookanevallev.orq
(Staff Use Only)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
[] DRIVEWAY [I PAVEMENT CUT (SEE BELOW) 0 SIDEWALK
[] CURB & GUTTER [] OTHER
ROAD OBSTRUCTION 0 NO
PROJECT ADDRESS:
YES ***TRAFFIC PLAN REQU ED� ii11
1 Project # ( /'U 5
START DATE: ANTICIPATED COMPLETION DATE:
BUILDING OWNER NAME:
NAME:
ra, ki7/1
ADDRESS: % 7�Cj't� Cc Gam— c�
(( (�- r
(e
CITY: PHONE: 2 7(% 7,7 Fp
STATE: r
FAX: CELL:
ZIP: /�
CONTACT NAME: j' H y lam//� ��jC_ 1/mot (/ y C- 7
PHONE: — � �(� FAX: .7. ,2 52( CELL: --7‘' 7.2
33 5`
CONTRACTOR NAME:
MAILING ADDRESS: 7// 7
CITY: 4 /J (/'e y
PHONE: 2 }.� 1 (40-2®Q
CONTRACTOR LICENSE No.:
STATE:
A
FAX: Z ` J 'n / 62 CELL:
EXPIRES:
-2/.9--33
CITY BUSINESS LICENSE NO.:
TIER:
POLICY:
BOND/INSURANCE CERTIFICATE #:
(PER SVMC TITLE 1
SIGNATURE:
****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
_
Sewer J ___—
Other
Effective October 28, 2007 Page 1 of 2
http://www.spokanevalley.org/fi lestorage/ 124/938/210/948/1496/Rig ht_of_W ay_(RO W )_Permit_App_1-11-11.doc
Asphalt (width X length)
Concrete (width X length)
Locate Ticket #:
X
X p
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:
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