RIGHT OF WAY (ROW) PERMIT APPLICATION
APPROACHPAVEMENT CUT (SEE BELOW)SIDEWALK
CURB & GUTTERWORK THROUGH MANHOLEOTHER
ROAD OBSTRUCTION NO YES(if yes, complete the following)
- % of street or # lanes that will be obstructed: ____
- Length of time street will be obstructed:______
If work closes more than 50% of a local access street, or closes any portionof an arterial street, then a TRAFFIC PLAN IS REQUIRED Pre-Approved TCP Proposed: _____
PROJECT ADDRESS:PARCEL NUMBER:
APPLICANT’S JOB #:LOCATE TICKET #
START DATE:ANTICIPATED COMPLETION DATE:
PROJECT DESCRIPTION:
PROPERTY OR BUILDING OWNER INFORMATION (IF APPLICABLE)
name:
mailing address: city: state: zip:
phone: fax: cell:
CONTRACTOR INFORMATION
name:
mailing address: city: state: zip:
phone: fax: cell:
contractor license no.:expires: city business license no.:
bond/insurance certificate # (per SVMC Title 10, Article 2):
contact name: phone:
**** IF PAVEMENT CUT, COMPLETE THE FOLLOWING ****
NATURE OF WORK:(circle one) / Gas / Electric / Water / CATV / Communication / Sewer / OtherTYPE OF CUT/REPAIR:(circle one) / Asphalt / Gravel / Concrete / Other
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.
EXPIRATION
Right-of-way permits issued between April 1st and September 30th 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 1st and March 31stare valid until the following April 30th.
Applicant Signature:Date:
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, 2014Page 1 of 2
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