HomeMy WebLinkAbout1425 S N St - Engineering
~-~. . PUBLIC WORKS CONSTRUCTION
~ and RIGHT-OF-WAY PERMITS
~ ; . City Phone: 206-457-0411, ex!. 124
......UCANT/OWNER" \ 1 h-. ~ (n;"r ). ADDRESS OF lOB: J 41~~ ~
APPUCANT ADDRESS: PHONE a.tPJk";/~,7- LEGAL OF lOB: L
WORK IS [J OUTSIDE or lJ INSIDE OF TRAVELED ROAD VALUE OF WORK IS: S"L '1 IJ Z (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.)
00408
PERMIT
"
PLANS REQUIRED lJ YES lJ NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED [J YES [J NO AMOUNT: $
PROOF OF INSURANCE: lJ WorIt $2.000 or leSs: $50,000 personal injury, $100,000 per incident, $20,000 property
[J Worle over $2,000: $200,000 personal injury, $500,000 per incident, S 100,000 property
[J Right of Way Use: $300,000 personal injury, $300,000 per incident, SIOO,OOO property
Pumi_ II%ldenlaDda that DO _ may be cloaed to bUfic unless approved by the City Engineer and Cbief of Police in advance of the
closure: thai there is a 24 hour minimum notice prior to inspection, and to call 48 hours before digging to: 1-800424-5555.
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Sipd: 4/1' - DATE: =3 J 9 k-,
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lEMOVAl.
ana u:nrr or WAY WOlK ""'" ALTD.ATIONI ...'"
IEPAlI. TO SEWER
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COMM. wATDIEJ.VICE 10 -1I,ClDQ MILWAUKEE DR. SEWER. ASSESS. U.3Q.ClO/EWM
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WATD': SD.YK:Ilo 0THEa EmMA'" RIOIn' OF W A V USE PERMITS VAA!ES U . SllXl
WATD SYS. OEV. CKAJ.OE ~02- TOTALS . . Oc;
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COMMENTS/CONDmONS:
O!DSlall [J Repair
OWatermain
o SaoiWy s.-
O SlDrm Drain
o Undergrouad Te1ephouelElectrica1 ~
JOOTTOTALS $ ;2.;2j(fJ -- RECEIPT # In1 ISSUED BY: 0 (r DATE:4Jf.7J
PW.0209.03 (12193)
INSPIlCI'OR.'S COPY . WIlIJ'E
WORK ORDER No.
00408
APPLICANT'S COPY. PINK OFFICE COPY - CANARY PERlIdlT
INSPEcnON FEES S