HomeMy WebLinkAbout1403 Shirley Ct - Engineering
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PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ext. 124
_",CANT""""" ~\!!> \-1",,;+ . AD~RESS OF i~'-1AJP, S~i ~":"\ g, ~r I
APPUCANT ADDRESS: PHONE ~CY'(pf1 LEGAL OF JOB: es \/ u. J H:1$'
WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD V~~F WORK IS:5 \,\.'Z.. L. I (if work is outside roadway
and is equal 10 or less than 52.000, then permit may be issued to other than licensed and bonded contnlctor.)
PERMIT
00412
PLANS REQUIRED 0 YES 0 NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: S
PROOF OF INSURANCE: 0 Work 52.000 or leis: 550,000 petllOllai injury, Sloo,OOO per incident, 520.000 property
o Work over 52.000: 5200,000 personal injury, 5500,000 per incident, 5100.000 propeny
o Right of Way Use: 5300,000 personal injury, 5300,000 per incident. 5100,000 propeny
Pennitteo UIldentllndI that DO .treet may be cloaed to tnffic unl_ approved by tho City Engineer and Chief of Police in advance of the
closure: that thoro is a 24 bour minimum notice prior 10 inspection, and 10 call 48 bou", before digging to: 1-800-414-5555.
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FEE 'AID TY>E FEE
IJOKTOF WAY EXCAV. ..... S~.~~EA (SfR) (6' 10'11.. 6.... lID" L-/ 5(0 Q.Q
-. ....... IAN. SEWEll. fUn, . hI .. -.00
<8Ill\11TIlt SI~.oo IAN SEWEIt tuFJl. ADD. UNrr ".00
DllYEWAY SI2s,cG V- I ~~!!.!2 IAN lEWD. 0T1IEIJ . Mlao-$7HXt ~7'ht
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REPAra TO SEWER
"'" IIYtlOANT DI'J'OSf1' ,. ) STORM DRAIN TAP SIU.(,I)
m. WATEJlIEKV1C'E Ie X Me "".00 /y 'V./. /7/5 {).f2.. CATCH BASINS rH Lan PEa EACH ....00
m. WAT'EI. SDVICE.- X )14- "".00 i
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m.WA $~SYS.I'IC'V.CHA.l(jC' I
CONM. WAT'EJ. SD.VICE I" .51,lXD MD..WAUKEE DR. .sEWEll ASoSW. S1XlmJEWM
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WATEJ. SD.YICE. 01lI!Jl EmMATE RIOHTOFWAY USE PERMrrS VAlUES U. SlCO
WATD. SYS. OEV. CHAJ.OE X'X':;? !JP.- TOT AU S s I' ~
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COMMENTS/CONOmONS:
[J InaIa1I 0 Repair
aWaIermain
a Sanitary Sewer
a SIomI DraiD
a Underground TelephonelEIOCIrical
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JOOT TOTALS sJ ~ ".5") ---- RECEIP1'
~~
#~ ISSUED BY: an
DATE:#h
WORK ORDER No,
OFFICE copy. CANARY PERMIT 00 412
INSPEcnON FEES $
PW~.03 (121931
INSPI!Ct'OIl'S COPY . WIlTTE
APPLICAI'n"S copy. PINK