HomeMy WebLinkAbout135 W Forest Ave - Engineering
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.vtUCANT/OWNER: Ed rz y,o..n
APPUCANT ADDRESS: PHONE LEGAL OF JOB:
WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD VALUE OF WORK IS:$ (If work is outside roadway
and is cqual to or less than $2.000, thCII permit may be issued to other than licensed and bonded cooenceo(.)
PLANS REQUIRED 0 YES 0 NO CONTRACTOR: DATES FOR START
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $
PROOF OF INSURANCE: 0 WorIt $2,000 or leis: $SO.OOO persona1 injury, $100,000 per incident, $20.000 property
o Work over $2.000: $200,000 personal injury, $Soo,OOO per incident. $100.000 property
o Right of Way Use: $300.000 pcrsonal injury, $300.000 per incident, $100,000 property
Pcrniiuee undentanda that DO _ may be cloecd to traflic unIea approved by the City Enain- and Chief of Police in advance of the
closure: that there i. a 24 hour m;n;rm'lD notice prior to inspection, and to call 48 hours before digging 10: 1-800-424-5555.
PUBUC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ext. 124
135
PERMIT ...!!..U..4..5.
ADDRESS OF JOB:
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& FINISH
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COMMENTSICONomONS:
a InIIaI1 0 RepUr
CWaIermIiD
C Sanitary Sewer
C SlDrIIl Drain
C Uadergraund TeiepboDelEleclrical
JOOT TOTALS $ tf/J eE-- RECEIPT
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ISSUEDBY:~ 1~
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DATE:~
WORK ORDER No.
INSPECI10N FEES S
PW~.03 (\21931
INSPI!CTOIl'S COpy. WIllIE APPLlCANr'S COPY. PINK OPFICE COPY. CANARY pERl\.fiT
00453
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