2015-04-21 Permit App ROW-2015-0199 Comcast CabinetSiftikane
Valley.
Community Development Department
Permit Center
11703 East Sprague Avenue, Suite B-3
Spokane Valley, WA 99206
Tel: (509) 688-0036
Fax: (509) 688-0037
permitcenterC&sookanevalley.ora
(Staff Use On)y)
PERMIT NUMBER:
PERMIT FEE:
RIGHT OF WAY (ROW) PERMIT APPLICATION
Li APPROACH E-1 PAVEMENT CUT (SEE BELOW) ED SIDEWALK
D CURB & GUTTER D WORK THROUGH MANHOLE El OTHER
ROAD OBSTRUCTION 0 NO D YES (if yes, complete the following)
• % of street or # lanes that will be obstructed:
• Length of time street will be obstructed:
i=> If work closes more than 500/0 of a local access street, or closes any portion of an arterial street,
then a TRAFFIC PLAN IS REQUIRED fl Pre -Approved TCP Proposed:
PROJECT ADDRESS: J110 S. Owt Cf- PARCEL NUMBER:
y
APPLICANT'S JOB #: /02,34/32. LOCATE TICKET # IS! 073Sl4f
START DATE: 1./ /2.2J2D1 5 ANTICIPATED COMPLETION DATE: 5-i5,20/5-
PROJECT DESCRIPTIO :
PI tii—e /0147 Com c Carb,xe -TA•nr Potkvf rob
)e4i»cl Sticle wail/ On 5 . p,c Rck he ki/eeil Fetich,' -t 5-tgebvp/4
Worh
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
NAME:
MAILING ADDRESS: CITY: STATE: ZIP:
PHONE: FAX CELL:
CONTRACTOR INFORMATION
NAME: 3 ef.01147-0:5-6-0-A-/Y1t4 fl c a 4.;o ei 5
MAILING ADDRESS: 0) J N.
PHONE: 509 53.2 -
611 -}0 e-oinccesf 631c
fv CITY: C.)(1i)t" Veillej STATE:
FAX: 50'i - _53.2 = 65)5
CONTRACTOR LICENSE NO.: 6o 1V, 1 i EXPIRES:
BOND/INSURANCE CERTIFICATE # (per SVMC Title 10, Article 2):
CONTACT NAME: t2a2 13rennc4n
CELL:
tAih ZIP: 9(72)6
CITY BUSINESS LICENSE NO.:
PHONE: 020t 7V-5
C/
V L:U
CSV PERMIT CENTER
APR 2 1 2015
1
Project # q01?-14/57:_• (MI
Name 77,
Submittal 4-
Modified April 14, 2014
htto://www.spokanevalley,org/filestorage/124/938/210/94e/1496/2831/ROWPA.cloC
Page 1 of 2
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK:
(circle one)
TYPE OF CUT/REPAIR:
(circle one)
SIZE OF CUT
(width) x (length)
Gas
Electr c
Asphalt
Water
Gravel
CATV I Communication
Concrete
Sewer
STAFF TO COMPLETE:
ROAD TIER: PAVEMENT CUT POLICY APPLIES?
Other
Other
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.
EXPIRATION
Right-of-way permits Issued between April 1" and September 30" 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" and March 31" are valid until the following April 30w.
Applicant Signature:
Date: 120 7/5
Method of payment: ❑ Cash ❑ Check ❑ Visa** ❑ Mastercard**
** If paying with credit card, the City will call for credit card information when the permit is ready to be issued.
PLEASE FAX TO CITY OF SPOKANE VALLEY (509) 688-0037 UPON COMPLETION
Modified April 14, 2014
www.sookanevall
lestorage/124/938/210/948
/$831/ROWPA.doc
Page 2 of 2