HomeMy WebLinkAboutEunice & Lopez - Engineering
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APPLICATION FOR PERMIT
OWNER ~ --'LA ~'J P L)
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(Print Name) . R-. J ;; V ~
N~
04800
City Engineer
Chief of Police
(date)
traveled roadway (if within traveled roadway, complete items 3, 4 & 5)
(If over $2,000 complete item 6)
OR
Work $2,000, and less. $50,000 personal injury, $100000 per incident, $20,000 property
Work $2,000 and more $200000 personal injury, $500000 per incident, $100000 property
6. Permittee understands that no street may be closed to traffic unless approved by the City Engineer and Chief of Police
notifications given to the Chief of Fire Department.
may be closed to traffic from to
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COMMENTS/CONDITIONS
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WATER MAIN
\ /' SANITARY SEWER
STORM DRAIN
TELECABLE
TELEPHONE UG
UTILITY POLE
In consideration of the granting of this permit, it is further agreed by the applicant that
the City of Port Angeles and any of ita officers or employees shall be 88Ved harmless
to the spplicsnt from any liability or responsibility for any accident, loss or damage to
persons or property, happening or occurring as the proximate result of any work
undertaken under the terms of thia application and the permit or permits which may be
granted in response thereto, and that all of said liabilities are hereby assumed by the
applicant.
Signed
Telephone No
Mailing Address
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1
2.
Work to be completed by
Location of work. Outside
Value of work to be performed
Contractor name
Performance Bond Amount
Proof of insurance
Inside
3.
4
5.
(street)
This certifies that the above named applicant is granted the permits to do the work described in and for the
pu'p068 shO'Ml in the application. Each permit is granted subject to the terms of tae agreement contained In
the said application and subject to the provisions of the code of the City of Port Angeles, and nothing
permitted hereunder shall be deemed to overnde the pfOvisions of any applicable law of the City, State or
Federal Goverrvnent
PERMIT
RIW
Sidewalk
CurbfGutter
Driveway
DwyfCu!vert
Sanitary Sewer
1 Residential
2. Commercial
3. Alter Repair
4 Tap
5. Cap
(includes WIM removal)
6. Secondary Sewer Treatment
Assessment
Storm Drain
1 Tap
2. C B.
Water Meter
1 5/8"
2. 3/4"
3. Commercial deposit
(Based on estimate 1 =$1,000.00 deposit)
4. Hot tap
5. Fire Hydrant install (deposit)
$40.00
60.00
60.00
60.00
40.00
80.00
30.00
125.00
225.00
125.00
40.00
475.00
500.00
250.00
Permanent
Gravel
Non-traveled
Curb removal
RESTORATION DEPOSIT
325.00
160.00
160.00
160.00
Permit total
Restoration total
TOTAL
Receipt No.
il
Issued by
24 HOUR MINIMUM NOTICE REQUIRED PRIOR TO SERVICE OR INSPECTION
Call 48 Hours Before You Dig 1-800-424-5555
Finance - Amount deposited $
Cost of repair (WIG #) $
Refund amount due $
Additional amount due City $
INSPECTOR'S COPY white APPLICANT'S COpy pink
Pen Print, Inc. 5/92
Work Order No.
PO No
Warrant No.
Receipt No.
PUBLIC WORKS
WORK ORDER #
PERMIT
OFFICE COPY canary
N~
04800
. . . . .
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . . . .
REQUEST'
Date /- / tJ - 91-
,
--
Time //#..?() A/Pl. Received by IRE"J//.4
,P
(phone, person)
Location of Work to be inspected 6N/C!E / LIJ PF"7
,/ ,.
Name of person requesting inspection B GtF~ C,.JAGS//;;',e"
Address of person requesting inspection S70,e/Yf TA ~ Phone No ;;-;fl: I~J
Type of Inspection (circle appropriate one) Permit No 4-?a 0
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav Other
j Al I-:::'"C) ON / V
. - /
INSPECTION NOTES
Inspected Date /- /0'" 94-
Remarks MJ4t>/E S'7iJ ~M 7it~
M-.J /;.., .:r^rrJF~ Se-cJT,,;AI t/.fGtJ
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Time /2:~" 1: lA, By j / K.
ON r'71~ t5'~e-6p {I J6' st:JuIA of
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RESTORATION REQUIRED
YESX
NO
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SURFACE RESTORATION'
SURFACE TYPE 0 Unimproved 0 Gravel ~Asphalt 0 PCC
o Repaired by City Work Order #
o Repaired by Permittee 0 COMPLETE
o No Damage Found 0 INCOMPLETE
o Other
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . . . .
REQUEST
Date
Time
Received by
(phone, person)
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
Phone No
Permit No
Sewer Excav ~~
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INSPECTION NOTES
Inspected Date ! - G - <7 L('
Remarks
Time
P n"
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By --(~ r .
(f (<) c-' r: T cj:+ --$ L
RESTORAT
. . YES NO
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SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel 0 Asphalt 0 PCC
o Other
o Repaired by City
o Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
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(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . . . .
REQUEST
Date
Time
Received by
(phone, person)
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
f~ t:i'
Lf' )
Permit No I
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Chimney Plumbing Final Sewer Excav cQ.!I1eP' so...."'" L"",^
Phone No
INSPECTION NOTES
Inspected Date / ~ I u - '7 f
Remarks
Time
A rJ 1
,
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By _/(~~--I-~
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( ,,)
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RESTORATION REQUIRED
YES
NO
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SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel 0 Asphalt 0 PCC
o Other
o Repaired by City
[] Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)