HomeMy WebLinkAbout506 E 5th St - Engineering
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...dUCANT/OWNER: SYYI ,-k en
00435
PERMIT
PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ex t. 124
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ADDRESS OF JOB: ::In II} t \. ) -
LEGAL OF JOB:G-..uz, \ c:;"""\ LT ?(
WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD VALUE OF WORK IS:$ (If work is outside roadway
and is equal to or less than $2,000, then permit may be issued to other than licensed and bonded contractor.)
APPUCANT ADDRESS:
PHONE
PLANS REQUIRED 0 YES 0 NO CONTRACfOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $
PROOF OF INSURANCE: 0 Work $2,000 or leSs: $50,000 personal injury, $100,000 per incident, $20.000 property
o Work over $2,000: $200,000 personal injury. $500.000 per incident. $100.000 property
o Right of Way Use: $300,000 personal injury. $300,000 per incident, $100.000 property
Permittee understands that no s~ may be closed to traffic unless approved by the City Engineer and Chief of Police in advance of the
closure; that there is a 24 hour minimum notice prior to inspection. and to call 48 hours before digging to: 1-800-424-5555.
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for.,1ICICi6cd, ordaDap~orprop=rt)', ~or~lIbpnQ:mlDrow!to(~ .-orklnic:rta=\R1orLbe"mII oIthia IppliatiOll ond lhc permil Of permil& ...-hidi~ybc ~ iIl_por>>c
u...o,lIId/1 olMidI1abi.'...bc byu.~.
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Sipod:. // fAt. ~J. DATE:$; /5,/1 G
;.,; .i . FEE I REO.D PAID I TYPE I FEE I REQ'O I PAID I
JJOHT OF WAY EXCAV. "".00 t../"" ~~lEWER (SFRl (6" 10 PIL.., 6".4' 110.00
~". "".00. S~. SE'NER t'MFR\ - III ...vI "'.00
lUlIOUlTEJ< SllS.CO SAN SEWER I'MFR . ADD. UNIT ".00
DOJVEWAY 1125.(1) SAN SEWER OTHERS . MiD-In.a>. $O.CW lit
Ma-S"O lOOO'lAMCI.OO25u",*,
~';"'-VDY ~. "".00 SEWER TAP- BY CITY NO 1123.OOI$JOO.00
wYElMANHOLE TAP
mEET CUT . ~ S>>:).OO SEWER CMfWATER METER 5225.00
REMOVAL
OTHEI. lJOilT OF WAY WOlK "".00 ALTERATION I SXl.OO V ~"30 ~ b
REPAIR TO SEWER
mE HYl)1W<T DEPOSIT STORM DRAIN TAP 512j.OO
m. WATEl SERVICE I" X SII' "!IO.OO -'750 ..eo CATCH BAS(/IIS IN LOTS PER EACH 5.o().00
an. WATElSEit.V1CE '" X )/.." "75.00 SECONDARY SEW'ER ASSESS. U1O.OOin$6I!1.000u..0i<k
RF.~,- WAT'n SFRVlCE'" X I" ~.oo .. ~)~.OO iEWM
SEWERSYS. DEV.CHARGE
COMM. WAT'El SElf.VJCE I" - 51,(XX) Mn.WAUKEE DR. SEWER ASSESS. SISO.OOiEWM
IW- 51.x,o
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WATEJ.,EJt.V1CE. 011ID ESTIMATE RIGHT OF WAY USE PERMITS VARIESS!I. SIOO
WATEl IYI. DEV. CHAJ.OE S7!1O.00~ TOTALS S S c:;g ()
ThiI-u&. u..tbI elv.oI-.dapplK:.nl. ~ U. pormi~ IOdou.9o'Ol"tdacribod iIl&r:d (<<!.be JlUI'P'Wthooo.1!. ill u.appli<ll.Uon. Eo.c:hpc:rmil iI &.tmIal"ubjeo;:c IOu... loC.... or de 11.1'OCInCIIIQXlU,in:d ill !.be applico,l;<X1
.., ~ 10 tbI ~ cllba City 0( Port Anploll M~ Cock. N<>lhinc pcrmillGd br.-.dcr u.u be dDcrnod 10 CMOrrl<lo:l the proviIic..-. of uty IpplK.olo: \.... or I.he Col). Coo.n). Sl.IloC Of Fedenl c.o...errmenl
COMMENTS/CONDITIONS:
D!nstall 0 Repair
DWatermain
[J Scritary Sewer
o Storm Drain
o Underground TelephonelElectrical
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I'
San Sewe r-- c.or. nec:I-;o Y]
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ISSUED BY: ,fr;...fi, f2/J
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.cKMIT TOTALS $
51SD ~
RECEIPT
#/C;ZG
DATE:#~
WORK ORDER No.
00435
OFFICE COpy" CANARY PERMIT
INSPECTION FEES $
PW-m09.03 1l2J93)
INSPECTOR'S COPY" WHITE
APPLlCA/IT'S COPY. PINK