HomeMy WebLinkAbout3932 Nygren Pl - Engineering
PREPARED 3/17/06, 11:58:50
CITY OF PORT ANGELES
PAYMENTS DUE RECEIPT
PROGRAM BP820L
A~PLICATION NUMBER: 06-00000249 3932 NYGREN PL
FEE DESCRIPTION AMOUNT DUE .
RIGHT OF WAY
TOTAL DUE
70.00
70.00
Please present this receipt to the cashier with full payment.
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~ORTANGELES
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WAS H I N G TON, U. S. A.
R!GHT,OF WAY USE.
p~RMiT HT;; #015.... 21.tq
NAME OF APPLICANT
MAILING ADDRESS
PHONE NUMBER
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DATE
7:,-/6-0b
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STREET ADDRESS OF PROPOSED STREET USE
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,
DESCRIPTION OF REQUEST (include drawings required for clarity): [If street closure is requested, please state the name
of the street and limits of closure, together with the duration of closure.] H. ' \ \
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<;.....oLv 'or ND D. f\\ A\. ~ N G,rtelV - I.:)
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IS THE USE TEMPORARY OR ~ANE~
HOW LONG WILL THE OBSTRUCTION BE IN PLACE?
WHAT ARE THE HOURS OF OPERATION?
HOW IT WILL BE LIGHTED?
EXPLAIN THE NECESSITY TO USE THE PUBLIC STREET, SIDEWALK OR PLANTING STRIP. ARE THERE
ALTERNATE AREAS THAT COULD BE USED?
HOLD HARMLESS and INDEMNIFICATION AGREEMENT
In compliance with the Port Angeles Municipal Code, and in consideration of the issuance by the City of Port Angeles of a Street Use
Penmit to the undersigned allowing the placement of the above described street use or obstruction, the undersigned for himself and
for his successors in interest, hereby agrees to indemnify, hoid harmless, and defend the City of Port Angeles against any claims or
lawsuits for personal injury or property damage arising out of, or in any way connected with, the placement of the use or obstruction
on the City street, sidewalk, or planting strip.
.....................................
. .
. .
. .
. .
Seal
H...................................
DATED;~yOf _
Applicant
,200~p
exCEc
SUBSCRIBED and sworn to before me this _ day of
,200~,
'.
'.....
~
NOTARY PUBLIC in and for the State of
Washington residing at
(This permit, if approved, may be terminated by the City of Port Angeles without cause and at any time)
(OFFICE USE ONL Y]
Copies sent to:
Police
Fire
Planning _
Finance
Date:
Fee paid $ Receipt #
Agreement to Remove Encroachment signed and
recorded on N/A
*************
Application reviewed and recommendation by City Engineer
deny or approve and with the following conditions:
Date application received
Certificate of Insurance per PAMC 11.12.140(B)
on N/A
Date
is to
Application approved or denied by the Director of Public Works
Date
...................................................................................................................h..h.........._.............................-..................-.-.........................-.-.-..........-.......
Copies to: Applicant 0 Fire 0 Police 0 Street 0 Other
o Address file 0 RUP file 0
RUP#
FROM
FAX NO.
:3604575901 Mar. 14 2006 03:37PM Pi
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Contractor fV{'.J.IJ .. " Ililll 0"5-14- Cl.o
WAVE
Prior'ilv ~~
BROAfBAND'. 1.) Out of Service
... () - /J 2.) New Sorvieo
Cu"ome,N.me ~J _ ,a.<<WC.C(JI v7L 3.)Tempor.ry
Service Addre.. ---:1 q ,1 ? A/y $3 V-e^'-.r,
._~ Dmp~n~
Silling Addres. "/;;L.., r:' /J ., " , Cabla TypolSlza
Ac;count Numb8l"
ID
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Job Tvne
Open Trench lD
Bury Drop %
~r
'{hI') - <J i ite'llWork
Permit ReQuirements
Road Bore
~~
Phone ," t.-
Drain fI'\ (CJ? ~.;,J..--
OIMr Sianel LeWl'1
'" P'lh'1do datallod thllJl 01 ro-'!llll"I"-...~O\IAA.'_elro/<lW~-'c""unde~'o~nd utllltl>>" drop rOUle '" 'tem' oI.c!",~[!l.' "~
Phone Number
Un09r Ground SBMcaS: V/N
SeptiC
Sprlnkl.r
Wat.:!,.
Electrical
e
Power
Driveway Borv
Right 01 Way
Blanket Permit
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Notoslln5troctions:
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