HomeMy WebLinkAbout611 W 11th St - Engineering
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PUBILIC WORKS & R/W PERMIT
OWNER/APPLICANT D Attached Notes
HILDE CRAWFORD
611 W 11TH ST
PW'CITY, PW'State PW:Zip
360/452-1922
PROJECT INFO
Work is
Plans Required'
Contractor'
Performance Bond Required
Proof of Insurance.
Work to Perform:
Issued
1 1
Permit No
Work Order'
873
o
PROPERTY LOCATION
611 11TH ST W
Lot: 18
Subdivision.
Parcel No
Block: 322
TPA
063000032285
o Long Legal
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Value Work:
$000
Start Date:
1 1
Finish Date
0001000-0000
1 1
~
Amount:
$000
PROJECT NOTES
o Install
o Repair
D Watermain
D Sanitary Sewer
D Storm Drain
D Underground Tele/Elec
D Misc
.............
'-...
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FEES ASSESSMENT
1 ) RIW Excav' $000 15 ) Other San Sewer' $000
2.) Sidewalk: $000 16) Sew Tap Wye/Man Tap $000
3 ) Curb/Gutter' $000 17 ) Sew Capl W/M Removal: $000
4 ) Driveway' $000 18 ) Alter Repair Sewer' $30 00
5 ) Dwy Culvert: $000 19 ) Storm Drain $000
6 ) Street Cut: $000 20 ) Catch Basin per ea. $000
7 ) Other RIW' $000 21 ) Sewer System Dev' $000
8 ) Fire Hydrant: $000 22.) Milwaukee Dr Sew Ass. $000
9 ) Res Water Serv' 0 $000 23 ) RIW Use Perm: $000
10 ) Comm Water Servo 0 $000 24 ) Admin Cost (0 R.A) $000
11 ) Other Water Service $000 25 ) 0 R.A. $000
12.)Water System Dev' $000 26 ) Misc: $000
13 ) San Sewer SFR. $000 TOTAL FEE, $30.00
14) San Sewer MFR. $000
add unit: 0 Amount Paid $000
Receipt No
Inspection Fee. $000 Balance Due $30.00
/'
Location of Work to be inspected
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one)
Sewer Foundation Framing Chimney
Plumbing Final Sewer Excav
INSPECTION NOTES .
Inspected Date / (- 5tJ-rr
Remarks
Time
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By
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RESTORATION REQUIRED
YES
NO
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SURFACE RESTORATION
SURFACE TYPE D Unimproved DGravel 0 Asphalt 0 PCC
o Other
o Repaired by City
o Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)