HomeMy WebLinkAbout520 E Park Ave - Engineering
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . . . . . . INSPECTION REPORT. . . . . .
REQUEST: &d-
//)/lrY --r'1 ~
Date ---Ii? Time Received by _ J--
(phone, person)
Location of Work to be inspected 52 D ~ P aAV
Name of person requesting inspection
Address of person requesting inspection Phone No.
Type of Inspection (circle appropriate one): Permit No. 3 (J 7
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other
INSPECTION NOTES: ! I .r.)
Inspected: Date ~ /2.- 1Y Time
Remarks:
PrYl
BYC~
RESTORATION REQUiRED...... YES
NO
~
d
, ~ /{)oifJ
\1/ .
,U
SURFACE RESTORATION:
SURFACE TYPE: 0 Unimproved OGravel o Asphalt OPCC
o Other
o Repaired by City
o Repaired by Permittee
o No Damage Found
~ 10,",;"," '" re~"..'" " ~~,..",
Work Order #
o COMPLETE
o INCOMPLETE
STREET SUPERINTENDENT
mATE I
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . . . .
REQUEST:~ ) sY
Date {( 1
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):
L!?Z-O E B/?/c
~~
.
<..J.G ,C.l:. rk
(D;l.~e ')
Phone No. ",/5(}.-77'1'T
Permit No. 50"?
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav. Other
5an/'57?n / c;(Pt/// B~d ~ /":::>p/2,t:"/;' 7-
INSPECTION NOTES:
Inspected: Date Time By
Remarks: ~ -/??1~L,_ ~tl...L.Z::- ~L r?/~... u.uu
~.A ~ {7AcI ~ 0-UlD~/ ~ O/~~ -
RESTORATION REQUIRED . . . . .. YES
NO
-:Z;Mre~J s.:T.C- .;l..-I'-~11' _..-vz.( w:r~
-roM h;..... he need.. 0:1 ...e/""r"'To.... ,n
a",d nee.ds 10 r...:~ e",Js oP p:re. ,'"
"-0 ..-;;:"c.1O r .. + c.:-r., f.u If ,
",.sf nor#urly e. Ii! ;" dwy
c., e:'> , ,'n ?,z...k.-." I.T.
~
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
~
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
-----
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When Recorded Return to:
stephen C. Moriarty
Platt Irwin Taylor
Colley Oliver & Moriarty
403 South Peabody
Port Angeles, WA 98362
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UTILITY EASEMENT
Grantor: st. Andrew's Episcopal Church
Grantee: city of Port Angeles
Legal Description: Portion of Lot 1, Sec 15, Twn 30N, R6W
Assessor's Property Tax Parcell's: 0630155091601000 &
0630155091602001
THE GRANTOR, ST. ANDREW'S EPISCOPAL CHURCH, (hereinafter
"Grantor"), in consideration of TEN DOLLARS ($10.00) and other
valuable
consideration,
receipt
of
which
is
hereby
acknowledged, hereby grants, bargains, sells and conveys to
CITY OF PORT ANGELES, (hereinafter "Grantee"), an easement on,
under, over and across the following described property:
THAT PORTION OF LOT 1 OF ST. ANDREW'S EPISCOPAL
CHURCH SHORT PLAT PER PLAT RECORDED IN VOLUME 28 OF
SHORT PLATS, PAGE 26, RECORDS OF CLALLAM COUNTY,
WASHINGTON, LOCATED IN SECTION 15, TOWNSHIP 30
NORTH, RANGE 6 WEST, W. M. . CLALLAM COUNTY,
WASHINGTON, DESCRIBED AS FOLLOWS:
COMMENCING AT THE SOUTHEAST CORNER OF SAID LOT 1,
SAID CORNER BEING MARKED BY A S/8-INCH REBAR WITH
CAP STAMPED "NTI-SCOTT LS 23400", THENCE ALONG THE
SOUTH LINE OF SAID LOT 1, NORTH 88015'36" WEST,
29.45 FEET TO A 5/8-INCH REBAR lfITH CAP STAMPED
"NTI-WALTERS PLS 22044" AND THE POINT OF BEGINNING;
THENCE PARALLEL WITH THE EAST LINE OF SAID LOT 1,
NORTH 4"00' 55" EAST, 19B,66 FEET; THENCE NORTH
B8"15'36" WEST, 116.03 FEET; THENCIl SOUTH 4"33'30"
WEST, 10.01 FEET; THENCE NORTH 88"15'36" WEST,
141.39 FEET; THENCE SOUTH 1"44'24" WEST, 188.50
FEET TO THE SOUTH LINE OF SAID LOT 1; THENCE SOUTH
88"15'36" EAST" 250,02 FEET TO THE POINT OF
BEGINNING.
EXCEPT THAT PORTION DESCRIBED AS FOLLOWS:
COMMENCING AT THE SAID SOUTHEAST CORNER OF LOT 1;
THENCE ALONG THE SOUTH LINE OF SAID LOT 1, NORTH
88"15'36" WEST 29.45 FEET; THENCE PARALLEL WITH THE
EAST, LINE OF SAID LOT 1, NORTH 4000'55" EAST, 30.02
FEET; THENCE NORTH 88015'36" WEST, 20.02 FEET TO
THE POINT OF BEGINNING; THENCE NORTH 4000'55" EAST,
138.61 FEET; THENCE NORTH 88015'36" WEST, 216.70
FEET; THENCE SOUTH 1044'24" WEST, 138.50 FEET;
THENCE SOUTH 88015' 36" EAST, 211.20 FEET TO THE
POINT OF BEGINNING.
ALL BEARINGS AND DISTANCES ARE RELATIVE TO THE
WASHINGTON COORDINATE SYSTEM, NORTH ZONE, NAD
'83( '91).
SITUATE IN_ CITY OF PORT_ ANGELES,_,CLALLAM COUNTY,
STAT~ OF WASHINGTON.
The purpose of this easement shall be for utility
purposes, including but not limited to sewer, water, power,
telephone and cable as well as for the purpose of entering upon
the premises to construct and maintain any such utility. The
terms of the easement shall be perpetual.
Dated:
c.!t (,/q 7
ST. ANDREW'S
a Washington
CHURCH,
corporation:
By: '1'J~,'",L c.,L
Name: MIchael G. Carr
Title: Rector/President
- 2 -
STATE or WASHINGTON )
)ss.
County of Clallam )
On this ~G7~day of June, 1997, before me the
undersigned, a Notary Public in and for the state of
Washington, duly commissioned and sworn, personally appeared
MICHAEL G. CARR, to'me known to be the Rector/President of ST.
ANDREW'S EPISCOPAL CHURCH, a Washington nonprofit corporation,
that executed the within and foregoing instrument, and
acknowledged the said instrument to be the free and voluntary
'act and deed of said corporation for the uses and purposes
therein mentioned, and on oath stated that he/she is authorized
to execute the said instrument.
day
WITNESS my hand an
and year first above wr
i and e state of
iding at {Port Angeles.
expires: \0 -2$'-2.0= .
- 3 -
// _ l "J'!;" ,~'
j'
,
----.- ------
CLALLAM COUNTY
In paY:~n:;;c~dr;;::.;~~;:l!~'~'~;"""""""""i"""""""'"''''''...............................~~~~.~c.l~S~..=~~l~~~.n
NUMBER WHEN FILED GRANTOR OR VEN~R GRANTEE OR VENDEE INSTRUMENTS I . FEES
'JUN 1 8 199
ffl 0
~ur,Audiwr
IBy ................................................................. .................. Depury.
I
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0tyrn;Nc Print.", Inc.
TO 94174709 P.02
02-20-1998 01:46P!1_~O~ ....-. ,__....._...., ...:......."-LI ""~&&'1.I."''''J.'.a.&1Il.'.1.
Project: 5+-. An dJre.<A) .s L,C. Address: ?dO &" fbr1c..
Installer: Smt.u.- ~ g'-(s~S Telephone: d-D0-<1.Jt>-/88(')
Address: II O'=' ~4"'" A-ve E" fC;;ccrnq I uJA P...r.mlL # Cfi-Iq - /3,q.;J.
Fire Sprinkler Acceptance Inspection & Tests
1. Una,;... y round
Witnes>;"d By:
flushed per NFPA 13.
*'
Date: j 1/'5 t17
.'
2. Underground piping hydrostatically tested at not less than 200 psi for two hours per
NFPA 13.
~ Witn",",sed Sy\,\).~ ~w.J1..J--=--- I Date: g!mQ'7 ~
J. luspection of piping for installation in accordance with approved plans and/or NFPA
13.
Witnessed By:
_1 r -
,~ <i1
4. Inapcction of piping being hydrostatically tested at 200 psi for two hours (inclUdes
1
al piping ~reviously tested) . Wet/dry system.
Witnessed By:~ .lit - Area: I ~). .il.ooo- Date: 1/1 e;-/qi
Witnessed By: lIrea, ;:In;/J .Aso.- !:late: II/~I Jq7
Witnessed By: Area~ .uf.h. Date: 11/;;1//97
S. Inspecti.on of piping bE.lllg air tested at 40 psi for 24 hours with less than l~ psi
drop.
Witnessed By:
1:..-
Start: Pr....: 42- ~; Ilnd P..-es: '--I;;;J 1'10:
6. Dry pipe val
teEt.
Witnessed By: t:.- _
()/C. GMd~~ ~/" oft' 8. .8to...."
~? Inc~etioa uf hack tlow prevent or
Witnessed By:
(to be
Time; cO 0 :sees
Fi"euo'?-e- ""A::; --=z'e....,,-ed. :C-)'
inspected by PubliCWorks)' ~..,..<!1i c..,Ke e:.
Date:
Wltnessed By:
tested. w-4 'SO
e. Sprinkler al
~-
9 . Two- inch
test.
Witnessed Sy:
t'-
Date: .9/19ho
10. Final inspection with cantrol v"-lve15 lu<::ked in open pOsition, Fire Department
connection . and system in service.
Date; B J 1'1 q ~
wllnC9sed Dy:
['polO
R"vi..M J./29197
IUIHL 1-'.11<'
02-20-1998 01: 45pr1 FROr1
TO
94174709
p.m
Port Angeles Fire De
partment 102 E. 5th Port nge es,
Company Name:
Contact Name: T~
Fu Number:
A
WA 98362
.4
Sent by: ~ fr1-ck~
Description:
Return FAX Number: (360) 417-4659
.'
Number of pages (including cover sheet):
'[2')
If there are any problems with this transmission.
please call 360-417-4655
CONFlDElvTlALITY NOTE: The informalion contained ill Ihis facsimile message is legally privileged and
col1f1dentlallllformalion intended only far Ihe use o/lhR individual 1/nmlity lIamM ah1/W!. Iflhe reader 1/f
IhlS message IS not the mlended reclplenl, yoll an hereby notijied tlml ""1 disseminalir:m. dislribulifm. or
copying of Ihis facsimile is striclly prohibited. If you h4ve receillea Ihis facsimile in error, pleQJe
Imm~dralcly nulify UJ by telephone and relurnlhe original message /0 us otlhe address set/orlh abolle.
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STATE OF WASHINGTON
.'.' DEPARTMENT OF HEALTH
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
N' In.tructlon. are not followed, sampJe will be rejected.
DATE COLLECTED TIME COLLECTED COUNTY NMlE
"e;;: /~DAY / YEAR ~: ~ Cl-
lYPE OF SVSTEM IF PUBLIC SVSTEM. COMPLETE:
&:!PUBUC . .~. " . C~GROUP
,.n INDIVIDUAL 11.0. No.1 /- c-., 5'" 5" A B
. (seMlsof'lylresldence) ," CC},15
. NAME OF SYSTEM r\
\_",v:"-:::::,~,,,,-'
.'~""-...C-,......-:;)
CTED
S7:tJ E
rae.
DAV(
EVENING ( )
OLLECTED BV: (Name) SVSTEM OWNER/MGR.: (Name)
(20 1- L..\-SLUO' i Cl-l-
SOURCE lYPE 0 GROUND WATER UNDER SURFACE INFLUENCE
o SURFACE .DJ WELL or ' 0 SPRING 0 PURCHASED Of 0 COMBINATION
. ~ WELL FIELD ',' INTERTlE or OlliER
SEN~EPORT TO: (Print Full Name, Address and Z~ Code)
~ t.l..\...Su)()((.".-.t_
(); I.?~.,.. ~ \ \<....(J
WASHINGTON
'"1'[;"-.(,-,
\,(~"''''f;:-r.,
I
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1-'
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,
I
!
lY OF SAMPLE (check only one in this column)
O ROUTINE, 0 Ch'^"c. Re . F
, DRINKING WATER _ IUIW....tad{ sidual:_Total_ reel
check: treatment t 0 Filtered
o untreated Of Other
o REPEAT SAMPLE
Previous coliform presen09 Lab.
Date
o RAW SOURCE WATER Source , ~ EIII
~ NEW CONSTRUCTION or REPAIRS
O' OTHER (Spedly)
~Total Coliform
o Fecal Coliform
REMARKS:
!
i,
i
,
i
I
I
i
I
, (lAB USE ONLY) DRINKING WATER RESULTS
o UNSATISFACTORV, Cofdorrns present o SATISFACTORV,
Co!lforms absent
REPEAT o E. Coli present o E Coli absent
SAMPLES
REQUIREO-- o Fecal present o Fecal absent
, OTHER LABORATORY RESULTS
TOTAl COLIFORM ----..Cl.... /100 ml E. COU _/l00mf
FECAL COliFORM 1100rni PlATE COUNT Iml
ANOTHER SAMPLE REQURED
SAMPLE NOT TESTED BECA.USE: TEST UNSUITABLE BECAUSE:
o Sample too old o Confluenl growth
o Wrong container o TNTC
o Incomplete lorm o Turbid culture
0 o Excess debris
SEE REVERSE SIDE OF GREEN COPV FOR EXPLANATION OF RESULTS
LAB NO. (7 DIGITS) DATE. TIME RECEIVED RECEIVED BY
:>? ~:1)-'11ID .
(~' . .'.
f l/~)
u.BORATQRY:
REMARKS
~ ~~! ~E~ ~~.:'!., n.
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$~
~
)UBLl~ ~vn~~ ~UN~lKULI1UN issued: 2/1M/98 TF Permlt No: 507
& R/W PERMIT Cond: Work Order: 0
)WNER/APPLICANT------------------------PROPERTY LOCATION------------------------
EPISCOPAL RET. HOMES OF W. WA : 520 PARK AVE E
703 CALLAHAN DRIVE : Lot:
BREMERTON,WA98310 : Block: 1 Long Legal:
360/3.77-0113 : Sub: MCGUIRESADD
'ROJECT INFO------------~---------------~---------------------------------------
Work is INSIDE traveled road Value Work: $0.00
CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Plans Required: YES
Contractor: PRIEST,GARY
Start:
Finish:
/ /
/ /
Performance Bond Required: N/A
Proof Insurance:
Amoun t :
$0.00
Work to Perform: INSTALL * Watermain
* Sanitary Sewer
* Storm Drain
Underground Tele/Ele
* Misc
'ROJECT NOTES-------------------------------------------------------------------
2" w/m dropin $1190(rec# 3299) $7064 SYSTEM USER FEE (WATER)
$5136.00 SYSTEM USER FEE (SAN) HOT TAP $331.95 (FIRE HYD)
sidewalk materials cost estimated @ $4,325.00(rec # 3300)
Partial payment 9/30/97
'ROJECT FEES ASSESSMENT---------------------------------------------------------
R/W Excav: * $40.00 San Sewer SFR: $0.00
Sidewalk: * $4,325.00 San Sewer MFR: * $280.00
Curb/Gutter: $0.00 Add Unit: 40
Driveway: $0.00 Other San Sewer: * $0.00
Dwy Culvert: $0.00 Sew Tap Wye/ManTap: $0.00
Street Cut: $0.00 Sew Cap/ W/M Removal: $0.00
Other R/W: $0.00 Alter/Repair Sewer: $0.00
Fire Hydrant: * $331.95 Storm Drain Tap: $0.00
Res Water Serv: $0.00 Catch Basin per ea: * $400.00
5/8" Sewer System Dev: * $5,136.00
3/4" Milwaukee Dr. Sew Assess: $0:00
1" R/W Use Perm: $0.00
Comm Water Serv: * $1,190.00 D.R.A.: $0.00
1" Admin Costs (D.R.A): * $0.00
1 1/2" Mi sc: inspect fees $450.00
* 2" ==============================
Oth Water Serv: $0.00
Water Sys Dev: * $7,064.00
TOTAL FEE:
AMT PAID:
$19,216.95
$19,216.95
Receipt No: 3813
Inspection Fee: $450.00
BAL DUE:
$0.00
R!W
SANITARY
WATER
DWY
STORM
DRA
OTHER
Separate Permits are required for electrical work, utilities, private and public improvements. This permtt becomes null and void ~ work or
construction authorized is not commenced wtthin 180 days, ~ construction or work is suspended or abandoned for a period of 180 days after
the work as commenced, or ~ required inspections have not been requested wtthin 180 days from the last inspection. I hereby certify that I have
read and examined this applicalion and know the same to be true and correct. All provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The granting of a permtt does not presume to give authority to violate or cancel the
provisions of any state or local law regulating construction or the performance of construction.
Sinnature of Contractor or Authorized Aoent
Date
Sionature of Owner (if owner is builder)
Date
c:
c:
ACCOUNT PERMIT ACCOUNT DOLLAR
NAME NUMBER NUMBER AMOUNT
L;OnStrucnon rUU.~L11
Plan Check Fee 700.9449
Surcharge ($4.50) 001.
Plumbing 700.9212
Mechanical 700.9213
Ign rUU.~L14
Electncal ~ermi\s I nspecnons ~~~e
House Moving
SldewalkIDnveway/Curb PermitlRl9hTOfwayPerm~ t:=;;? J ruu.~, CL/J_
Publications ruu.
BluepnnlS- Aenal rUU.~4L~ ~
Fnglneenng SeMce ~ees <:::: /').- rUU.~462 <J. ~"7'T -
Clear/Graae ~ermrt ru~
Ire Inspecll ermltt-ee OUU. ff
Ire Spnnk er Plan ReVIew Fee
Admlnls ranon cost (5%)
ees Plus Interest UU1.
JtllA 65U.L"1~LUU
tnWt::K1M~WKWWf9JAUJi.~NEB~ttfflJ...~pA~tQHJmM@~t%Ht ~)rJr.QJA:l.HHn :HHh9P..~~: ........ ..... . .)t:1*~~ %hMNWMffWJM@Hf#Ml%WWm
Storm DralnlTap L.,- /)-"] 19 ./
StreeV Alley Restoration
SIW Co-Op
M*:='$%f ,~.;. ~H=~~#!W:t::..:. , , .......\@mrW.:...tW#::.:.;:::~< ~:~?:.... . \Pt\ #M~:;" -" "* ..~~V.: .. ?:- .:'M!M~'~ .:~. :::V.$-::. .;>;~,:;
'. .. ..-....- :.;. ... ..
other Fund
:m:::~4:..)~ ;. "':..'.:... /€DE~#ill!:i@~ tM~I~~~::mJ~ :i:t:,!:W' ::, \ .:::t.::: " :t*:$@tUffi4>}:~tlhWMN:.m~:ar.~!
.. " , .. ...i':d .. .. ..
IProperty Sales 715.9634
lW:tHtFith :;'<:' :....,..~%MqM:}H~ gm~g!~~YH? :}f@t .. , .ilitmt.?: IrW)MJ~Ngk'~'t.:?M~MNRnWWjn
, .. ....;.. .. .,....
IWater System ueve ope men! l,;narge . "s 7) '7 r 7/
IHot Tap Iwatermalnl ;;..
IF.H. InstalV Meter c;- 00 r~j.~ol~ ..':j~. 'f''':>'''
IWIM Installation 753.~o' ~
r::~;:;?:<<-M~... ::%~~ ~$.;:;:~;:;: \ .::W:~!~:~wn~:: ,,'::::::~VWd:: ~}:w ';W:$~:' :m'::f.:H:' .' , 'rn'K#:::'::::::'<,;:;(;'W " ,:~P.@.~ij?:~%ij~~::t.#@)
.. ....... ..... ':'..
ISanrtary Sewer I aprl,;ap or MRlap j~4.~bl~ --;;;:;
Sewer System Uevelopement C arge "~4.~4U" 7/
ISaMary Sewer permrt 7 )-'7 354.9223
~ , , M::::-;f;:. , Ell ~.;""., >< :~@:W , .', .~~t.::~~~n:::~::;&;1~
::-:.... ','9.'= " ;. ,." "
.... ..
IMilwauKee LJr Assessment ,"~.~4U3
:~~; l.:;:-:'\ ?~:::::,: .. ,. ...... ~{ .....;.::..>..,...~2tWlHfl@Mth:9.<~M 43.%~4.MKWWt HH<... t', ~ '1t',.g-:::m~:%li:WMW#t*f"a~#
..:-;. .. .,
I
I
I
V/..;: , ." .' , .:-; :::;: i '.QNimYtlUOm"..l!NDt,' ,. ~ ~ .:.m':%f:r.:7~W ~:::?:: ,::;!; . ; , rA.;:,.~" .AK*hHm ~.
.. , l:.:\./.
ISeconaarv Sewer Assessment 757.9633
, .. ," . Y~~~&.T
w~" ::!:-::~:.,~::::,W:::~}~ ....... . ,r:-:, ";;::: ::=:.' ..;."~~:. )::':B*..:-:'. ..,..; " ',-
RECEIPT # N 0 3 8 1 3 _SiD'ltoif '~~"1?>& . i'$$
- i. ,',,' - :) :.',;:' :.;, ,"... .:.::: : :......:::(.. ..'. './.~~f:.{;.; ....,:'.,.. ,:..,:
~ILL-IN : I CL.. T-I U I1\L ALL ~
CITY OF PORT ANGELES PUBLIC WORKS DEPARTMENT
SZCJ. e- ~-+/eK -41= 507
E';; / ~ {!c)~;#!f L ~ HfTS
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~;;;;.'
CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DIVISION
32\ EAST 5TH STREET, PORT ANGELES, WA 98362
PUBLIC WORKS CONSTRUCTION Issued:
& R/W PERMIT Cond:
OWNER/APPLICANT------------------------PROPERTY
EPISCOPAL RET. HOMES OF W. WA 520
703 CALLAHAN DRIVE Lot:
BREMERTON,WA98310 Block: 1 Long Legal:
360/377-0113 Sub: MCGUIRES ADD
PROJECT INFO--------------------------------------------------------------------
Work is'INSIDE traveled road Value Work: $0.00
Permit No: 507
Work Order: 0
LOCATION------------------------
PARK AVE E
/
/
Plans Required: YES
Contractor: PRIEST,GARY
Start:
Finish:
/ /
/ /
Performance Bond Required: N/A
Proof Insurance:
Amount:
$0.00
Work to Perform: INSTALL * Watermain
* Sanitary Sewer
* Storm Drain
Underground Tele/Ele
* Misc
PROJECT NOTES-------------------------------------------------------------------
2" w/m dropin $1190(rec# 3299) $7064 SYSTEM USER FEE (WATER) oJ.
$5136.00 SYSTEM USER FEE (SAN) HOT TAP $331.95 (FIRE HYD)~;:-j.J,S W'J'\'5 .4'Pq5Cl~t
sidewalk materials cost estimated @ $4,325.00(rec # 3300) c.~t=:-J<Et)()~c:()1i
Partial payment 9/30/97 Ii...-.-€' &Lnci.MATEJ::IAt
PROJECT FEES ASSESSMENT---------------------------------------------------------
R/W Excav: * $40.00 San Sewer SFR: $0.00
Sidewalk: * $4,325.00~pd. Ifj/BD/47 San Sewer MFR: * $280.00
Curb/Gutter: $0.00 Add Unit: 40
Driveway: $0.00 Other San Sewer: * $0.00
Dwy Culvert: $0.00 Sew Tap Wye/Man Tap: $0.00
Street Cut: $0.00 Sew Cap/ W/M Removal: $0.00
Other R/W: $0.00 Alter/Repair Sewer: $0.00
Fire Hydrant: *$331.95 Storm Drain Tap: $0.00
Res Water Serv: $0.00 Catch Basin per ea: * $400.00
5/8" Sewer System Dev: * $5,136.00
3/4" Milwaukee Dr. Sew Assess: $0.00
I" J R/W Use Perm: $0.00
Comm Water Serv: * $1,190.00~~~13P 47 D.R.A.: $0.00
I" Admin Costs (D.R.A): * $0.00
1 1/2" Misc: inspect fees $450.00
* 2" ==============================
Oth Water Serv: $0.00
Water Sys Dev: * $7,064.00
R/W
SANIT AR Y
$0.00
WATER
T~*Lpr~~: 2S;:;i~:;~41
----------------------- ~oL
BAL DUE: $13,701.95 'I
Receipt No:
Inspection Fee:
DWY
STORM
DRA
OTHER
Separate Permits are required for electrical work, utilities, private and public improvements. This permit becomes null and void if work or
construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after
the work as commenced, or ff required inspections have not been requested within 160 days from the last inspection, I hereby certify that I have
read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not The granting of a permit does not presume to give authority to violate or cancel the
provisions of any state or local law regulating construction or the performance of construction.
Sionature of Contractor or Authorized Aaent
Date
SiQnature of Owner lif owner is builder)
Date
-po tUor 'Po r XI?
____ V5 7>rrrr5
/ ~ Vnhl 'plI-ye~
/ / Permit No: 507 ~
Work Order: 0 I
LOCATION------------------------
PARK AVE E
In
pv//
PUBLIC WORKS CONSTRUCTION Issued:
& R/W PERMIT Cand:
OWNER/APPLICANT------------------------PROPERTY
EPISCOPAL RET. HOMES OF Y. YA 520
703 CALLAHAN DRIVE Lot:
BREMERTON,WA98310 BLock: Long LegaL:
360/377-0113 I Sub: MCGUIRES AOO
PROJECT INFO--------------------------------------------------------------------
Work is INSIDE traveled road Value Work: $0.00
PROJECT NOTES-------------------------------------------------------------------
II w/m dro in $1190(rec# 3299)system user $7064 san sew sys user fee
$5136.00, "1 w/m dropin $200, sys user fee $2207, hot tap for FH $950
ldewalk s cost estimated @ $4,325.0QCrec # 3300
Partial payment 9/~97
PROJECT FEES ASSESSM~~--------------------------------------------------------
R/W Excav: * $40.00 San Sewer SFR: SO.OO
Sidewalk: * $4,325.00 San Sewer MFR: * $280.00
Curb/Gutter: SO.OO Add Unit: 40
Driveway: SO.OO Other San Sewer: *
Dwy Culvert: $0.00 Sew Tap Wye/Man Tap:
Street Cut: SO.OO Sew Cap/ Y/M Removal:
Other R/Y: SO.OO Alter/Repair Sewer:
Fire Hydrant:"" S950.00 Storm Drain Tap:
Res Water Serv: SO.OO Catch Basin per ea: ....
5/8" Sewer System Dev: ....
3/4" Mi lwaukee Dr. Sew Assess:
Plans Required: YES
Contractor: PRIEST,GARY
Start:
Finish:
Performance Bond Required: N/A
Proof Insurance:
Amount:
work to Perform: INSTALL"" watermain
.... Sanitary Sewer
.... Storm Drain
Underground Te(e/Ete
.... Mise
1"
R/W Use Perm:
O.R.A. :
Admin Costs (D.R.A): ....
M i sc: ; nspect fees
Comm Water Serv:
.... 1"
SO.OO
1 1/2"
.... 211
/ /
/ /
I'(m~
SO.OO
;?OD
"7 "2- oi ~-''YYl
~~
SO.OO
SO.OO
SO.OO
SO.OO
SO.OO
5400.00
S5,136.00
SO.OO
SO.OO
SO.OO
SO.OO
5450.00
"11 q 0 EE-
4325 ~
1(;5/6 2.E. P PI
~7
~
/
------------------------------
------------------------------
Oth Water Serv:"" S1,390.00
Water Sys Dev:"" S9,271.00
TOTAL FEE:
AMT PAlO:
Receipt No:
Inspection Fee:
SO.OO
BAL OUE:
S22,242.00
S5,515.00
S16,727.00
(
ons rue on
PlariCl1ecK Fee
Surcnarge ($450)
Plumbing
Mechanical
Sign
Efec::trical Permits flnspections
House Moving
Sidewalk/Driveway/Curb PermiURight of Way Permit
Pubficafions
BTueprTrlls- Aerial
Englneenng S'eiVTce J=ees
CJeailGiaae Permit
Fire lnspecUPermit Fee
Fire 5prlnkfer Plan Review Fee
Aifiriln1sfraffon Cost (5%)
DRA Fees Plus Interest
CITY OF PORT ANGELES PUBLIC WORKS DEPARTMENT
ACCOUNT PERMIT ACCOUNT
NAME NUMBER NUMBER
700.9449
001.22111000
700.9212
700.92D .
700.9214
91f.9237
TOIT.~
700.9128
700.94OlJ
7009429
700.9452
700:9241
500.9671
500.9449
700.9425u--
001:2392000
DOLLAR
AMOUNT
f'BiA 650.2319200
m:w:::::'m7gi911W.~I'i~p.BaI2Eg~P;:{I::;gI0TI;n22.I.T()Tl\\';;I .' t!im1il1;tlQW:l:;;lE
storm TIiainfTap
SffeetTAlley Restoration
sm Co-Op
. --752W19
752.9242
752.-0026
:.:.:.:...:-:.:.:-:.:.:......
'.r'.'r"TQ'!~k'}IRl:l:JH'IDN ~_;""~'.,.'.;,...",..'.';G;_.._.
TRr
:::"::::::;
-":':"':'.:.:.:.:.:.:.~:.:.:.:.:.'.',.'
OfherTuna-
.'r"i'IQT~PlWrr~~MI'iNTfm\!P':.r
L~'~~_ .,,_~.~.~~~c
tit..., .l&flt!l!lll9::;'"
~~~~~~fT~T~H'E~Qy:!;~TEYF!:fIri8T;:rr ~':...19I~iIE;m;ql~i;='~'~~Er
aferSystem Developement Charge
ot Tap\Walermain)
F.H Tnstal11 Meter. . . _ ..1/ ___
~:;i'~;:~::~~~'~;~~~B~P'iiili{'~0bg;
SanlfiliYSewer TapfCap or MH Tap
Sewer SYstem DevelopemenfCliaige
~a,,-1\i3f)' Sewer PermiT -- -. .-
;T,.........
...~.~\)rr;" ...
. 753:9403'
-753."9619
~.951"9
753.9619
-/7Q(2~
::;:;:::;;;:;::/:::::::::tt~::;~:~:~:~:~:~~:~r::::::<:;i:t:t{{y{:~:::'::::
n -"3!)4.9()19
354:9403
354"9223
....:;T'!'l'QtJ\hVl\A!?'(j;:WA!~RruND':
~. Jm2iJJ. 'mlOQ-'~'.'
. ..... -' .--.......
.... .. .........
::"~;/:"_..,. .::..: ::: :,: c. , .. .y:~:'::::r:~
MilWaukeeDi Assessment
755:ll403
:~Sr{2iT.'l;.:70IA.!:\'IQ!J.P'W~f,'fl,ll'l!t:::::::;::::;........
,'.'."'.rri4lfil. ....WftS'lOOlt'r:.)..'.'.
............."................,-,.......
._._._..~~....._...........
.;::;S.E,:rLlo.Ig~.W;:~gJl!~JI~I!.-gI!QJ'l.IJ!II!'fL~....___
...::~~lmIl9'r:'.:.::::.
/5T.9"633
Secoila~ry Sewer Assessment
. (UAti&fWERIMl:lRQVSHNTROND;;
RECEIPT# No 3299
,.;.......,........
(;.../o.'s.: ,",Ptt..1.L u.:C It';') A'_"' /) 1'1 ft/afa.1
-'~:. ,/;!. (/(//,1 ,. J', L'
! -'5;< ().E !~? It )
\
CITY OF PORT ANGELES PUBLIC WORKS DEPARTMENT
ACCOUNT PERMIT ACCOUNT
NAME NUMBER NUMBER
DOLLAR
AMOUNT
ons rue on
Pra-n -cneek Fee
SurenargeTR5U)
Plumbing-
Meenanlear
Sign
ETectrfeall'eimns Ilnspeenans
H6u~ovmg------- - - -- -- ---
SfdewaIKlDrlVewaylCuroP-e-rm1l1Rignt of Way Permit
Pubneanons--- - -
Bluepnnts- AenaT
Englneenng Service Fees-
Clear/Grade Permit - --
FirelnspeetlPermrt~e-
Fire SpnnT<1erPlai1Revlew Fee-
Admlnlstraijon Cost (5%)
DRA Feesl'rus Interesr
- 7009449
---mn 2291000
7009212
700.9213
7009214
-911.9237
700JJ626
700.9228
700.9401l
700.9429
700 9462
7009241
6009677
1300_9449
700.942-5
m ll01.2392000
P81A650 2319200
iIiEEDmBiI9T~~!!it!E_lFQNP.mmi1E'mEIbdE:TQI~:IT: s::H!Pigl\1;:llilJ!!lPBi@I
S!armTIiaTnTTap 752.9619
StfeevAJIey RestoratTo-~- _=-===-~ 752:9242
s~-_~____ _ 752:9026
::}:I/!~it...I., . ...:.:;.:.::...........
-.q'07,? 2::: ~
"'-- -::../ ~.::-?
'''.:::.:I.}:r::::,,,,.. ;:&l:':::1:$;,~':"J;,,;I?
Olner Fund
.. }:&'?TQrAlliqAP!Y~~EtII!!iNT:fU-NP:I :::}.]t9TA4II ':'mF~111jM!(1!l@ ::%;?
I'r~j~:~~~~~k~J~Qygl!~NTFQ;~;"""@i08 E'rrQ~F' EJ-TI~~;:i1:i~@ii"
atersy81iiiTIlJevelapemenf Cnarge
at Tap (waterman,) ----- . - .
R InstaIlMete'--
Installation'
753.9403
-7539619
- 7539519
753.9619
I,:: ........ ........IIW:~t1M!lWl'?HbK
354JJ619
--'354U!,403
3549223---
;F~;1l~?::"":
7559403
San1!a,yseweTTaprcapai MH Tap--m
SewerSysTemlJevefopement naige .
SanifarySewerl'ermlt _'
:......::,)TQ'fm;:;viNHB~~I'!':ll'fILNP...:.-7J'F]:
Milwaukee DiAssessment
@mUiSmiiliflfQT~;~9J![w~f!1!?MtlQj;;iBf\JirUi;;E
.:LJ!!;@;\111f@1fE[iJ@i
2-TIjf@wmQTm.i;!~;;YiilQP.R~!BQS1!21IijfI1NP1JiliFw
.;;;1J~;;11P;1J!@Zii;;;;if:
757.9533
Seco.iil1arySeweJAsse"sment
RECEIPT #
::. PR"OVEMENT::........
N~ 3300
..;N:":~...:.:
.:;~:~~:~::{:j:~::j:~tn~:~::j::::
.
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/ ,-/ /, / ~~i' .//(
CITY OF PORT ANGELES
321 East Fifth Street, PO Box 1150
PUBLIC WORKS Port Angeles, Washington 98362-1150
Phone (360) 417-4805
Fax (360) 417-4609
TIY Phone (360) 417 -4645
e-mail papwdept@olympus.net
June 3, 1996
t' oi5:~~
\/~lllq(
Rob Linkletter
13 24 E. First Street
Port Angeles, W A 98362
RE: Installation Estimate for Sidewalk at
Saint Andrews Episcopal Church at
510 E. Park Avenue
Dear Rob:
Enclosed is the estimate for the installation of a sidewalk that you requested for Saint Andrews
Episcopal Church at 510 E. Park Avenue.
Under the City's cooperative sidewalk program, the property 0 er accepts responsibility for
payment of the materials only, with the City provi . and equipment for the installation.
The estimated cost of materials for this project .
480 feet of sidewalk, reconstruction of six drive
If you are interested in the sidewalk program, please submit the estimated amount shown above,
or, if you prefer, we will bill you when the project is complete.
If you are interested in installation of the sidewalk using city forces,. please contact me at 417-
4802. Projects for co-op sidewalks are being scheduled now and construction should begin in the
next two to three weeks.
Very truly yo
~~
Deputy Director
enc.
Par.C:\DATA\WP\l996\LINKLETT.KDR
-.
t
Seo-19-97 02:10A DAVE BAUBLITS / W.G. CLAR 360 452-7913 P.02
r'U~1 MI'HJ('LC.v '-.111 .Lf l.V..jOU-'U(-Lj(U:::l .)t.t"" l':l":;f( 1,):,)( NO.UU::' r'.U~
v'.u.,~ ~'_~'v
CITY OF PORT ANGELES
~~- _.-
-
---~ - -
--
321bsll'ifrll Screer. PO llox ) J 50
I'UlllLlC WORKS Port Angele5, WlISbingtQn 96362.1 J SO
PllUtlC (JoO) 4/7.4R05
fa, (160)417-4609
TrY I'boJ1<O (360) 417-4645
e-mail papwaept@olyrnf'u,.ncl
September 19, 1997
Episcopal Retirement Homes
of Western Washington
220 West Mercer, Ste SOD
Seattle, WA 98119
RE, Two inch drop in water meter fee and sidewalk material costs
520 East Park Ave, Port Angeles
Dear Sir:
Per W.G. Clark's request for fees regarding the installation of a
2" (drop in) water meter at the above address is $1190.00. The
material cost for sidewalk construction is $4,325.00.
The remaining permit fees may be paid upon further completion of
the building project. Upon receipt of payment the Water and
Street divisions will schedule their work accordingly.
If you have any questions regarding this, please feel free to
contact me at 417-4807.
Si~cerely, ~
.J~~
Trenia Funston
Engineering Permit Specialist
c/$t L{Zjo3
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NORTHWESTERN TERRITORIES, INC.
Engineers. Land Surveyors. Planners
Construction Coordination. Materials Testing
717 SOUTH PEABODY. PORT ANGELES, WASHINGTON 98362 -(360) 452-8491
5c!10 E POA1u
Perm; t No: 507
York Order: 0
lOCATION------------------------
PARK AVE E
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PUBLIC WORKS CONSTRUCTION Issued: / /
& R/U PERMIT Condo X
OUNER/APPlICANT------------------------PROPERTY
EPISCOPAL RET. HOMES OF U. UA I 520
220 U. MERCER, STE 500 I lot:
SEATTlE,UA98119 I Block: long legal:
206/286-9951 I Sub: MCGUIRES ADD
PROJECT INFO--------------------------------------------------------------------
Work is INSIDE traveled road Value Work: $0.00
'* Storm Drain
Underground Tele/Ele
'* Mise
PROJECT NOTES- - - - - - - - - - - - - - ----- - - - - - - - - - - - ----- - - - - - - - - - - - - - - ------ ------------
J"(Compound) w/m dropin $1580/sys user fee $13245/san sew sys user fee
$9630/1" w/m dropin $200/sys user fee $2207thot tap for FH $950
Plans Required: YES
Contractor: PRIEST.GARY
Start:
Finish:
Performance Bond Required: N/A
Proof Insurance:
Amount:
Work to Perform: INSTALL '* Watermain
'* Sanitary Sewer
*****************$33307.00 total owing*******************
--
/ 3 245
2z07~
/ ?462 50
I
/ /
/ /
$0.00
;.JoT TA-p qSO
/ S~OtTO 3 f'd4p~
20{)eJ2 ;"~~
PROJECT FEES ASSESSMENT---------------------------------------------------------
R/W Excav: * $40.00 San Sewer SFR: $0.00
Sidewalk: * $41325.00 San Sewer MFR: * S280.00
Curb/Gutter: $0.00 Add Unit: 40
Drlveway: SO.OO Other San Sewer: *
Dwy Culvert: SO.OO Sew Tap Wye/Man Tap:
Street Cut: SO.OO Sew Cap/ W/M Removal:
Other R/W: SO.OO Alter/Repair Sewer:
Flre Hydrant: * S950.00 Storm Crain Tap:
Res Water Serv: SO.OO Catch Basln per ea: *
5/811 Sewer System Cev: *
3/4" Mllwaukee Cr. Sew Assess:
111 R/W Use Perm:
COfI1Tl Water Serv: S200.00 C.R.A.:
* 111 Admin Costs (C.R.A):
1 1/211
Mise: lnspect fees
------------------------------
------------------------------
2"
Oth Water Serv: * S1,580.00
Water Sys Dev: * $15,452.00
TOTAL FEE:
AMT PAID:
Receipt No:
Inspection Fee:
$0.00
BAl DUE:
$0.00
$0.00
$0.00
$0.00
$0.00
$400.00
$9,630.00
$0.00
$0.00
$0.00
$0.00
$450.00
$33,307.00
$0.00
$33,307.00
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CITY OF PORT ANGELES
~
321 East Fifth Street. PO Box 1150
Port Angeles. Washington 08362-11 SO
Phone (360) 417-4~()5
Fax (360) 417-4609
TTY Phone (360) 417-4645
e-mail pap\\.'depl@o]ympus.l1ct
PUBLIC WORKS
September 19, 1997
Episcopal Retirement Homes
of Western Washington
220 West e 500
S e, WA 98119
'703 faU~~j)~
~~/ YJ/A-Qf3/0
RE: Two inch drop in water meter fee
520 East Park Ave, Port Angeles
and sidewalk material
p~ 507
costs
Dear Sir:
Per W.G. Clark's request for fees regarding the installation of a
2" (drop in) water meter at the above address is $1190.00. The
material cost for sidewalk construction is $4,325.00.
The remaining permit fees may be paid upon further completion of
the building project. Upon receipt of payment the Water and
Street divisions will schedule their work accordingly.
If you have any questions regarding this, please feel free to
contact me at 417-4807.
J;;::~
Trenia Funston
Engineering Permit Specialist
,
APPLICATION FOR WATER
City Water Deportment
Port Angeles, Wosh
f/~S-/q7
, 19
I hereby apply for water fa be furnished '1 accordance .....th rates and ri.J~(,s of the City
for the following premIses'
Nome of ApplieontEJ=7.s6/1Y'L /':c/ ' ~/77C:S C,E ft', /t.7'lS/:;L,
o .v 70 3 ("~LLA-H-4A.J
Address 520 E r/?,,^ 15 i-''f'n-?,gr"la'7
, Il/t1-Cj8/c;
Renewol New Ser",ee --- Blk / Lo',dO /11/lqv//ce:5
Size of Service :2 --I ~t:?-/h Iv\eter ,"'WfI 0\.'r
, {t'C....',Pt1t/nd) V
Serv,ee Left On Serv,ee LeI! Off S gned/\ f f
Instolled by
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WATER DEPT. METER CHANGE
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NAME: EP,'3C'o PAl.- !if~T I-Iom"'"' ,,/- ,t, 1-1 ~ H
ADDRESS: 5 Z-. e r
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DATE: 10-1 ~ C[7
ACCL #:
OLD METER #:
FAviOi:r q 73 q Bf; t{ 3
NEW METER #: 7 c; 10
READING:
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REMARKS: 0 1<- 0 (J I IV
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QL YMPlC PRINTERS INC.
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The IlNKLETfER Associates
Dl:sign . Planning. Programming
1324 East First Street
{JOI1 Angeles, \,\lA 9H362
300 4574819 Fax 360 457A,jOH
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July 24, 1997.
Mr. Lou Haehnlen. Building Official
City of Port Angeles
321 East 5th Street
Port Angeles, Wa. 98362
RE: Sewer Line Abandonment
Dear Lou.
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Accompanying this letter is the notarized "Waiver and Release" form the City of Port Angeles
has requested regarding the existing sewer line at St. Andrew's Place.
This letter is to verify that at no time in the future, can the City come back and ask for
removal of this abandoned line.
Should you have any further questions on this matter, piease feel free to contact me.
fV.Ee,
(j)
CY
~
Best regards,
Robert G. Linkletter. Principal
The LINKLETTER Associates
cc:
Jeff Williams
David Steele
Don Nielsen
W.G.Clark
St. Andrew's Place
Chilless Nielsen
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WAIVER AND RELEASE
''--'.'
FOR AND IN CONSIDERATION of permission from the City of
Port Angeles for the right to: ?,BANGCN f>>-l E,XI<STlt--100EWE'f',
L-I NF- \HE L.lf-Je IS '3~" BELoW THE Foorn--iGS AND WILL NOT
C1<Fi6'r--E:::. AN p:a/E?PSE CONDITIoN UCC:g'[)lt-..I G N.T.I.
on the property located at:
S120 EA'ST t='Af<:.!<. (ST ~5 F-F!ecor.~l_
"-
C-H UFCH)
the undersigned, for themselves, their hcirs, succcssors and
assigns, hereby waives, releases, and forever dischar<;cs any claims
against the city of Port Angeles or its Cl.lploy"es for personal
injuries or damages arising out of t':" .::.,::" c::":o the above
referenced property for the purposc <.S .. .. . ""'c.
The undersigned further agrees that they will save and
hold the city of Port Angeles harmless from and defend the City
against any and all claims and causes of action for personal injury
or property damages to third persons arising out of or in any way
connected with entry onto City property.
Dated this
23
day of
-.JULY
, 19"1l
STATE OF WASHINGTON )
) ss:
COUNTY OF CLALLAM )
On this S-z:f day of 4//ef , 19 97 ,
before me, the undersigned, a Notary Public in a.d f:r the State of
Washington, duly commissioned and sworn, r :r~~.~~lly .~~cared ____
. f?O/J'~ ef "/'/?1\/k'i-~rrr:>;zto me kno'; 1 to. L~. . t~e individual
described in and who executed th<; fR.'i('~~/';"t ni,::s~n'~ent, and
acknowledged to me that (s)he signed and scaied the saltl lnstrument
as his/her free and voluntary act and deed for the uses and
purposes therein mentioned.
~9 LiM~
Given under my hand and official seal the day and year in this
certificate first above written.
PW104
4/23/90
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NOTARY PUBLIC in and ---for the
State of Washington, residing
at Port Angeles, Washington
,
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CITY OF PORT ANGELES
~
321 East Fifth Street. PO Box 1150
Port Angeles. \Vashington 0X361:-1150
Phone (360) 4\ 7,4805
Fax (360) 417-4609
TTY Phone (360) 4\7,4645
e-mail papwdL:pt@olympus.net
PUBLIC WORKS
September 19, 1997
Episcopal Retirement Homes
of Western Washington
220 West Mercer, Ste 500
Seattle, WA 98119
RE: Two inch drop in water meter fee and sidewalk material costs
520 East Park Ave, Port Angeles
Dear Sir:
Per W.G. Clark's request for fees regarding the installation of a
2" (drop in) water meter at the above address is $1190.00. The
material cost for sidewalk construction is $4,325.00.
The remaining permit fees may be paid upon further completion of
the building project. Upon receipt of payment the Water and
Street divisions will schedule their work accordingly.
If you have any questions regarding this, please feel free to
contact me at 417-4807.
j~:~
Trenia Funston
Engineering Permit Specialist
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . . INSPECTION REPORT. . . . . .
REQUEST:
Date ;- ;; - f 7
Time I: CV F'.M
Received by If 1(. '-
(phone, person)
-
Location of Work to be inspected ;- I y:
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one):
Sewer Foundation Framing Chimney Plumbing
rA If Ie
151'-(
Phone No.
Permit No.
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.
Final Sewer Excav. Other
,t?f.t, .? >1 S
Inspected: Date
Remarks: H b I
INSPECTION NOTES:
9 -; -9 7
T/tP rp;t
Time ? '" C# r -"'1 By ~t"1l1'
/I/E/I<. rlRiE HYptff-4lV~
RESTORATION REQUIRED. . . . .. YES ~NO ~
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SURFACE RESTORATION:
SURFACE TYPE: 0 Unimproved DGravel
o Repaired by City
o Repaired by Permittee
o No Damage Found
o Asphalt 0 PCC 0 Other
Work Order # r Y-?
[B-COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
COST A NA LYSI S '1 f 9
18 WORK ORDER NO.
LASO R 18 ---- CITY OF PORT ANGELES PERMIT NO. ,5() r;
EQU IPMENT ;' r, PUB L1C WORKS DEPARTM ENT
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::2/8 :!2- WOR K OR DER REPORT 9 - ? - 9 ;7
MATER IALS DATE -
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WATER D I V I S I ON \...~ /
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TOTAL $ 0 DEPQSI r PAID AMT. $
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CHARGE TO 0 BALANCE DUE $
ADDRESS 1 7 t h & " B " ( Cor p Ya rd ) 0 REFUND DUE $
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DESCRIPTION T;<J I" (; X' G h T-11" LOCATI ON , P'A ~ ;::
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SP EC I A L INSTRUCTIONS ,
labo r ~ TOTAL HOURL.Y ,u.n
DATE HOUltS S I Z E STOCK o. AMOUNT AIC
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BACKFLOW DEVICE TEST REPORT
CITY OF PORT ANGELES
PUBLIC WORKS DEPARTMENT
WATER DIVISION
RETURN NO LATER THAN:
NAME OF PREMISES: ~-+, fl.11""/1'i...~"\ P/I't('~
SERVICE ADDRESS: ,~2 0 ~. PA '" t A <.J.:-
DEVICE:
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Manufacturer
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Model
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Size Serial No.
LOCATION OF DEVICE: U 0 V'..j...-c- <;.. i'l ~-
IS THIS AN APPROVED DEVICE? YES IS3' NO 0 IS DEVICE INSTALLED CORRECTLY YES (lY"NO 0
DATE OF INST ALLA TION / Y <;., UNKNOWN 0
LINE PRESSURE AT TIME OF TEST:!il. LBS. PRESSURE DROP ACROSS FIRST CHECK VALVE: 3 LBS.
CHECK VALVE CHECK VALVE DIFFERENTIAL PRESSURE
NO.1 NO.2 RELIEF VALVE
I. LEAKED 1. LEAKED 1. OPENED AT _ LBS REDUCED
lNlTIAL TEST PRESSURE
2. CLOSED J~HT V 2. CLOSED TIGHT ~ v' 2. DID NOT OPEN
AT PSI , <;" AT PSI I,,;;
REPAIRS CLEANED CLEANED CLEANED
REPLACED: REPLACED: REPLACED:
DISC DISC DISC. UPPER
SPRING SPRING DISC. LOWER
GUIDE GUIDE SPRING
PIN RETAINER PIN RETAINER DIAPHRAGM. LARGE
HINGE PIN HINGE PIN UPPER
SEAT SEAT LOWER
DIAPHRAGM DIAPHRAGM DIAPHRAGM. SMALL
OTHER. DESCRIBE OTHER. DESCRIBE UPPER
LOWER
SPACER. LOWER
OTHER. DESCRIBE:
FINAL TEST CLOSED TIGHT V' CLOSED TIGHT ...... OPENED AT LBS. REDUCED
PRESSURE
-
AIR GAP INSPECTION: REQUIRED MINIMUM AIR GAP SEPARATION: YES 0 NO 0 '
REMARKS: AJ....-~,d J: uc" -f-,q..( II~ +to 0 iJ - Xr. i<?#,I, '(JIll -S r ') ft"M/1 .
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THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
STATUS TESTER NAME TESTING FIRM CERT. # STATE CONTRACTOR'S DATE
LIC. #
INmAL TEST BY:
REPAIR BY:
FINAL TEST BY: 3. ~ . 'L .,.c,/ A' I(','~ A.f' fJ4. 'i32tf-'>.,e, I /-y- 7~
PW.903.02 5/961 ,
WHITE - CUSTOMER COpy
YELLOW - PURVEYOR COpy PINK - TESTER COPY
DEVICE #
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BACKFLOW DEVICE TEST REPORT
CITY OF PORT ANGELES
PUBLIC WORKS DEPARTMENT
WATER DIVISION
RETURN NO LATER THAN:
NAME OF PREMISES:
ST
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f fill( /c
ft./! Ct:-
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SERVICE ADDRESS:
LOCATI61'.rOF~DEVICE: ee HI/tI J?
DEVICE: A M E 5
Manufacturer
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Model
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Size
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Serial No.
IS THIS AN APPROVED DEVICE? YES I9"1'fO 0 IS DEVICE INSTALLED CORRECTLY YES ~O 0
DATE OF INSTALLATION 11 tj 7 UNKNOWN 0
LINE PRESSURE AT TIME OF TEST:U LBS. PRESSURE DROP ACROSS FIRST CHECK VALVE:~ LBS.
CHECK VAL VB CHECK VALVE DIFFERENTIAL PRESSURE
NO.1 NO.2 RELIEF VALVE
I. LEAKED I. LEAKED I. OPENED AT - LBS REDUCED
INITIAL TEST PRESSURE
V v-
2. CLOSED TIGHT V 2. CLOSED TIGHT 2. DID NOT OPEN
. AT PSI AT PSI
REPAIRS CLEANED CLEANED CLEANED
REPLACED: REPLACED: REPLACED:
DISC DISC DISC. UPPER
SPRING SPRING DISC. LOWER
GUIDE GUIDE SPRING
PIN RETAINER PIN RETAINER DIAPHRAGM. LARGE
HINGE PIN HINGE PIN UPPER
SEAT SEAT LOWER
DIAPHRAGM DIAPHRAGM DIAPHRAGM. SMALL
OTHER. DESCRIBE OTHER. DESCRIBE L"PPER
LOWER
SPACER. LOWER
OTIlER. DESCRIBE:
FINAL TEST V V V ~
CLOSED TIGHT CLOSED TIGHT OPENED AT LBS. REDUCED
PRESSURE
AIR GAP INSPECTION: REQUIRED MINIMUM AIR GAP SEPARATION: YES 0 NO ~
REMARKS: fJllf/Rt.c cHerie -(Jill FIRE JrJ'Tc./0
THE ABOVE REPORT IS CERTIFIED TO BE TRUE:
STATUS TESTER NAME TESTING FIRM CERT. # STATE CONTRACTOR'S DATE
LIC. #
INmAL TEST BY:
REPAIR BY:
FINAL TEST BY: Rpt1/ IE c/Ce/l.. CfTy of f. .A Ifi J 'f (j 'f oHNi
pw.9Q3.02 (jl96j
WHITE - CUSTOMER COpy
YELLOW - PURVEYOR COPY PINK - TESTER COpy
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ST. ANDREW'S RETJREIVi
703 CALLAHAN DZ~T COMMUNITY
. BREMERTON, WA 98130
! :i!::~_ ~ 1904 ~
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,J U . BDNKOme. I GTONGTON 88101 \
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OPERATING ACCOUNT
703 CALLAHAN DR
BREMERTON, WA 98310
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K ,2nd Avenue
Seanls, WA 98104-0547
" 447-2222
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