HomeMy WebLinkAbout926 W 4th St - Engineering
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00351
PUBUC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ext. 124
,v"uCANT/OWNER:IC,C!...ha.i'"d.~h'h.S . ADDRESSOFJOB:3W W 4-\,h
APPUCANT ADDRESS: PHONE LEGAL OF JOB: w'l..L.rv: E851 L.TI 1511;: ~A?>
WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD VALUE OF WORK IS:5 (If work is outside roadway
and is equal to or less than 52,000, !hen permit may be issued to o!her than licensed and bonded contractor,)
PERMIT
PLANS REQUIRED 0 YES 0 NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: 5
PROOF OF INSURANCE: 0 Worle $2,000 or leis: $50,000 personal injury, $100,000 per incident, 520,000 property
o Worle over $2.000: 5200,000 personal injury, 5500,000 per incident, 5100,000 property
o Right of Way Use: 5300,000 personal injury, $300,000 per incident, $100,000 property
Permittee undentaDda that no street may be closed to traffic unless approved by tho City Engineer and Chief of Police in advance of !he
closure; that !hero is a 24 hour minimum notice prior to inspection, and 10 call 48 hours before digging to: 1-800-424-5555.
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S;pd~~~:t?2~~..- DATEY->~/~ ~~
TYPE F>E .""" 'AID TYPE FEE lEO'D 'AID Ii
<If) 00 9D'lE I
lJOHrOF WA.Y EXCAV. ...... V ~~~EIlISf.1 16' 10 PIl- 6'...' ......
........
~.... SAN'. SEWEJt ""',,--. hi \Dia .....,
<lUlUI'm< S12!.m SAN' lEWD. IUfI,l. AOO. UNrr "...
DllVEWAY slum SAN lEWD. OTHEIS . MIII.ns.CQ: ~Mo.crm a_
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DWY CULyaT ...... ~~~.'!~~O SI2SJDUXlJD
srJ.EEt' cur . ........ Dlll... ~ '?IJn ~ SEWD. CAPIWATEk METER. .""...
It.EMOVAL
0T1II!I. JJQHt' 0' WAr WOIK ...... ALTERATION' IJO...
kEPArJ. TO SEWn
..... HYDllANT DEPOSfI' STOlM DRA[H T A' Im.OJ ...- IZ6021
m. WATn IBVICE I- X "'- .....m CATCH IA.Jlf'rfS rH LOTS PER EACH '.0111 I
m. WAT'EI. SDV1C'E ,- x "..- sm." V .-<,?;, O.f;. , Ii
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COItOol. W"TD. SDVICE I' - lip>> Mn.WAUKEE Oil. SEWEl ASSESS. '130.00 fEWM 2"'~< ~
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"'''Tn SD.VICE. 0TREJl ~ llOKr OF WAY USE ~rTS VUJES U. SIOO
""ATn $YS. DEV. CHAJ.OE 2?'i?~ '?J2 Tar.... . ,
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COMMENTS/CONDmONS:
O!nllall 0 Repair
CWatermain
C SaDitary Sewer
C Storm Dnin
C UndagrouDd TelephonclEIectrical
"ttMIT TOTALS $ 2 -::, 4- S--
RECEIPT
#
I 'l B2- ISSUED BY:
~
DATE:~q(.
PW.0209.03 (111931
INSPECTOIl'S COPY . WIlrTE
WORK ORDER No.
00351
APPUCANT'S copy. PINK OFFICE COPY . CANARY p~
INSPECTION FEES $