The URL can be used to link to this page

Home My WebLink About904 S Pine St - BuildingPREPARED 7/07/09 9 42 02 INSPECTION TICKET PAGE 5 CITY OF PORT ANGELES INSPECTOR JAMES LIERLY DATE 7/07/09 ADDRESS 904 S PINE ST SUBDIV TENANT NBR LEE R /SHIRLEY M HUNT CONTRACTOR GARLAND CONST MAINT PHONE (360) 457 5186 OWNER LEE R /SHIRLEY M HUNT PHONE (360) 452 6500 PARCEL 06 30 00 0 2 9600 0000 APPL NUMBER 09 00000641 RE ROOF PERMIT BNOP 00 BUILDING PERMIT NO PR FEE REQUESTED INSP DESCRIPTION TYP /SQ COMPLETED RESULT RESULTS /COMMENTS BL99 01 7/07/09 JL BLDG FINAL July 7 2009 9 40 08 AM 1pangrle GARLAND 457 5186 BLDG FINAL RE ROOF HOUSE COMMENTS AND NOTES CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY ECONOMIC DEVELOPMENT BUILDING DIVISION 321 EAST 5TH STREET PORT ANGELES WA 98362 Application Number Application pin number Property Address ASSESSOR PARCEL NUMBER Tenant nbr name Application type description Subdivision Name Property Uge Property Zoning Application valuation Application desc TEAR OFF RE ROOF HOUSE T:FormsBuilding Division/Building Permit 09 00000641 Date 6/29/09 531153 904 S PINE ST 06 30 00 0 2 9600 0000 LEE R /SHIRLEY M HUNT RE ROOF RS7 RESDNTL SINGLE FAMILY 8780 Owner Contractor LEE R SHIRLEY M HUNT GARLAND CONST MAINT 904 S PINE ST 2512 E RYAN DRIVE PORT ANGELES WA 98362 PORT ANGELES WA 98362 (360) 452 6500 (360) 457 5186 Structure Information 000 000 TEAR OFF RE ROOF HOUSE Permit BUILDING PERMIT NO PR FEE Additional desc TEAR OFF RE ROOF HOUSE Permit pin number 149328 Permit Fee 193 75 Plan Check Fee 00 Issue Date 6/29/09 Valuation 8780 Expiration Date 12/26/09 Qty Unit Charge Per Extension BASE FEE 95 75 7 00 14 0000 THOU BL -2001 25K (14 PER K) 98 00 Other Fees STATE SURCHARGE 4 50 Fee summary Charged Paid Credited Due Permit Fee Total 193 75 193 75 00 00 Plan Check Total 00 00 00 00 Other Fee Total 4 50 4 50 00 00 Grand Total 198 25 198 25 00 00 Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned fora period of 180 days after the work has commenced. or if required inspections have not been requested within 180 days from the last inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does notpresume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance s construction. Of A� z4; Print Name Signature of Contractor or Authorized Agent Signature of Owner Of owner is builder) -744(e_ei BUILDING PERMIT INSPECTION RECORD PLEASE PROVIDE A MINIMUM 24 -HOUR NOTICE FOR INSPECTIONS Building Inspections 417 4815 Electrical Inspections 417 4735 Public Works Utilities 417 4831 Backflow Prevention Inspections 417 4886 IT IS UNLAWFUL TO COVER, INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED POST PERMIT IN CONSPICUOUS LOCATION. KEEP PERMIT AND APPROVED PLANS AT JOB SITE. Inspection Type FOUNDATION Footings Stemwall Foundation Drainage Downspouts Piers Post Holes (Pole Bldgs PLUMBING Under Floor Slab Rough -In Water Line (Meter to Bldg) Gas Line Back Flow Water AIR SEAL. Walls Ceiling FRAMING Joists Girders Under Floor Shear Wall Hold Downs Walls Roof Ceiling Drywall (Interior Braced Panel Only) T -Bar INSULATION Slab Wall Floor Ceiling MECHANICAL. Heat Pump Furnace FAU Ducts Rough -In Gas Line Wood Stove Pellet Chimney Commercial Hood Ducts MANUFACTURED HOMES Footing Slab Blocking Hold Downs Skirting T.FormslBuilding Division /Building Permit Date PLANNING DEPT Separate Permit #s SEPA. Parking Lighting I I ESA. Landscaping I I SHORELINE. FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/ USE Inspection Type Electrical 417 -4735 Construction R.W PW Engineering 417 -4831 Fire 417 -4653 Planning 417 -4750 Building 417 -4815 Accepted By Comments FINAL Date Accepted by FINAL Date Accepted by Date Accepted By '7=1- OQ 0 .s� f Applicant or Agent Property Owner's Address d Contractor /Engineer O y 6 „o c, s Contractor /Engineers Address License Expires PROJECT ADDRESS go ci 5, P iVle, S Parcel Number Project Tvpe Brief Description: Check all that apply New Construction Addition Remodel Repair 6X-roof Demolition Heat System Other Floor Areas Existing (sq. ft.) Proposed (sq. ft.) Basement 1st Floor 2nd Floor 3` Floor Garage Carport Covered Porch Deck Shed Other Total footprint of structures sq. ft. T' Lot size Max. height of proposed structures ft. Occupancy group Will a lawn sprinkler system be installed? Occupant load Will a fire sprinkler system be installed? Construction type I have read and completed this application and know it to he true and correct. I am authorized to apply for t understand that it is my responsibility to determine what permits are required, and to obtain permits prior projects. Dat Property Owner CITY OF PORT ANGELES Attn Building Permit Technician 321 E. Fifth St. Port Angeles, WA 98362 (360) 417 -4815 fax (360) 417 -4711 Frnt Name(); BUILDING PERMIT APPLICATION Print in ink esidential z to Heat pump wood- burning stove Phone Phone 941.04e 4 r Signature E -mail Lot Zoning Commercial Multi- family Industrial .1)e70 J gas fireplace pellet stove other per sq. ft. f�10,�- 2�ia1S L�bn r For City Use Only Date Received {n 9 Permit Phi —0-I 1 Date Approved of bedrooms of full baths of half baths TOTAL VALUATION 7 0) sq. ft. Lot coverage lis permit and o working on Wel.7 0 fa <11 0 if71 .4 of X- Age et:zipt:4.c.c9rulq„gpp.-3y 4 Date of ;46ceptanco r ht4agyiN'z i o v n 4 Utfi kiappveet4.ttioatat-IA,49 beyond ow "Sri.:4343- 29 7fs4W.IF" Tao ,c-q t ..w..' -4,.: The hereby '6 01 yfei";,r.f61.e4riTaptt icitiOdIO:CfCi'Me .:vvoix 4s;,i).§-0ifro'61: @WO,: .2. Payments .Will be made as o ilinectaboye. s- Signptura—± nn. FecGf" pages -,:=iit,7 4 Ttop tArOhliect :RO.0,1 y and or delays 10(44,' f",7 Mote this proosma be...wi;hdroyn.01,us.if.notA4c6pteci,with)11 day _n crrv ov vo 'r · (.~) PUBLIC WORKS - BUILDING DIVISION eAS'r s'ru svu e-r, A?aa e s, WA 9836 BUILDING PERMIT ISSUED: 6/14/2001 PERMIT NO: 12729 OWNER/APPLICANT PROPERTY LOCATION LEE HUNT 904 PINE 904 PINE STREET Lot: N1/2 1&2 Port Angeles, WA 98362 Block: 296 [] Long Legal 360/452-6500 Subdivision: TPA T: S: Parcel No: 063000029600000 CONTRACTOR ARCHITECT OWNER N/A VARIOUS Port Angeles, WA 99360 , 98360-0000 206/000-0000 360/000-0000 PROJECT INFO Project Value: $4,000.00 SFD Units: 0 Commemiah 0 Project Type: GARAGE NEW SFD SQ FT: 0 Industrial: 0 Occupancy Type: RESIDENTIAL Garage: 0 Occupancy Group: MFD Units: 0 Construction Type: MFD SQ FT: 0 Zoning Use: PROJECT NOTES DETACH GARAGE 440 SQ FT FEES ASSESSMENT Building Permit: $97.25 Misc Fee 1: $0.00 Plan Check: $0.00 Misc Fee 2: $0.00 State Sumharge: $4.50 Misc Fee 3: $0.00 House Moving: $0.00 Manufactured Home: $0.00 Sign: $0.00 TOTAL FEE: $101.75 Plumbing: $0.00 AMOUNT PAID: $101.75 Mechanical: $0.00 BALANCE DUE: $0.00 Radon: $0.00 Separate Permits ara raquired for electrical work, SEPA, Shoraline, ESA, utilities, pdvate and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned i for a pedod of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have raad and examined this application and know the same to be trae and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herain or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of construction. Signatura of Contractor or Authorized Agent Date Signature of Owner (if owner is builder) ' Date ~ -VORT ~ .....J"O~~ C~<!, "-~ ~ ~~ CITY OF PORT ANGELES DEP ARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION 321 EAST 5TH STREET, PORT ANGELES, WA 98362 Application Number Property Address ASSESSOR PARCEL NUMBER: Application description Subdivision Name Property Zoning . . . Application valuation 03-00001028 Date 10/21/03 904 SPINE ST 06-30-00-0-2-9600-0000- PUBLIC WORKS UTILITES o Owner Contractor LEE R./SHIRLEY M. HUNT 904 SPINE ST PORT ANGELES WA 98362 OWNER Permit Additional desc Permit Fee Issue Date Expiration Date DRIVEWAY INSTALLATION Plan Check Fee Valuation 145.00 10/21/03 4/19/04 .00 o Qty Unit Charge Per Extension 145.00 BASE FEE Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 145.00 145.00 .00 .00 Plan Check Total .00 .00 .00 .00 Grand Total 145.00 145.00 .00 .00 ~ ~ ..:t:. ~ ~ :::. ~ V\ :-f Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authOrity to Violate or cancel the provisions of any state or local law regulating construction or the performance of construction. Signature of Contractor or Authorized Agent Date Signature of Owner (If owner is bUilder) T \PLANNING\FORMS\1102 15 [4/2002] f'PORT~ ^"-4.0~~ U,.'"' "- -=-- ~ ~~ Application Number Property Address ASSESSOR PARCEL NUMBER Application description Subdivision Name Property Zoning Application valuation CITY OF PORT ANGELES DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DNISION 321 EAST 5TH STREET, PORT ANGELES, W A 98362 D 3 _ / () Zn 03-00001028 Date 10/21/03 904 SPINE ST 06-30-00-0-2-9600-0000- PUBLIC WORKS UTILITES o (1./ S ~\ 'f' ~D~ Owner Contractor ------------------------ ------------------------ LEE R /SHIRLEY M HUNT 904 SPINE ST PORT ANGELES WA 98362 OWNER ---------------------------------------------------------------------------- Permit Additional desc Permit Fee Issue Date Expiration Date DRIVEWAY INSTALLATION 145 00 10/21/03 4/19/04 Plan Check Fee Valuation 00 o Qty Unit Charge Per Fee swnmary Charged Paid Credited Extension ~ Due BASE FEE Permit Fee Total Plan Check Total Grand Total 145 00 00 145 00 145 00 00 145 00 00 00 00 00 00 00 Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last inspection I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority tOfi late or cancel the provisions of any state or local law regulating construction or the performance of construction. 7/1 A ''"'''--_/' - 10-2/-03 ~.# It ~_._. Signature of Contractor or Authorized Agent Date Signature of Owner (if owner is builder) Date T"\PLANNINGIFORMSIII02.15 [4/2002] BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER, INSULA TE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE INSPECTION TYPE DATE ACCEPTED COMMENTS YES NO FOUNDATION FOOTINGS WALLS FOUNDA TlON DRAINAGE ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT # ROUGH-IN PLUMBING UNDER FLOOR / SLAB ROUGH-IN WATER LINE GAS LINE BACK FLOW / WATER AIR SEAL WALLS CEILING I FRAMING JOISTS / GIRDERS SHEAR WALL WALLS / ROOF / CEILING DRYWALL T-BAR INSULATION SLAB WALL / FLOOR / CEILING I MECHANICAL HEAT PUMP WOOD STOVE / PELLET / CHIMNEY HOOD / DUCTS PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'s: WATERLINE / METER SEWER CONNECTION SANITARY STORM PLANNING DEPT SEPARA TE PERMIT #'s SEPA. PARKING/LIGHTING ESA. LANDSCAPING SHORELINE. FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE I ACCEPTED I YES NO ELECTRICAL LIGHT DEPT 4 I 7-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION R.W / PW/ CONSTRUCTION R.W ENGINEERING 4 I 7-4807 PW / ENGINEERING FIRE 4 I 7-4653 FIRE DEPT PLANNING DEPT 417-4750 PLANNING DEPT BUILDING 417-4815 BUILDING T-IPLANNINGIFORMSI11 02.15 [4/2002] BUILDING PERMIT INSPECTION RECORD CALL 417-4815 FOR BUILDING INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER, 1NSUIMTE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE INSPECTION TYPE [ DATE I ACCEPTED COMMENTS YES I NO FOUNDATION: ELECTRICAL (LIGHT DEPT) SEPARATE PERMIT: # PLUMBING UNDER FLOOR / SLAB ROUGH-IN WATER LINE GAS LINE BACK FLOW / WATER AIR SEAL CEILING FRAMING JOISTS / GIRDERS SHEAR WALL WALLS / ROOF / CEILINO ~ -- 17 -O" ~' ~. DRYWALL T-BAR INSULATION SLAB ] WALL / FLOOR / CEILING MECHANICAL HEAT PUMP WOODSTOVE / PELLET/CHIMNEY / INSERT HOOD/DUCTS PW UTILITIES / SITE WORK (Englneerin g Division) SEPARATE PERMIT #'s: WATERLINE / METER SEWER CONNECTION SANITARY STORM PLANNING DEPT. SEPARATE PERMIT #'s SEPA: PARKING/LIGHTI NG ESA: LANDSCAPING SHORELINE: FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED YES NO ELECTRICAL - LIGHT DEPT. 417-4735 ELECTRICAL LIGHT DEPT CONSTRUCTION R.W. / PW/ CONSTRUCTION - R.W. ENGINEERING 417-4807 PW / ENGINEERING BUILDING 4174815 ¢~ )'~ --0 t ~-~tO~b BUILDING IF OR OFFICIAL USl~ ONLY: ~'°~x~'~-~e._ BUILDING PERMIT - APPLICATION I ~: I ~: ~.-/~-~{ I ~ A~:,, PI~I ~ or p~t ~ ~ ~you ~w any qum~ pl~ ~ 417~81~ ~c~~: ~ Phone: ~ Ad.ess: ' / Ci~: - / ' : Zip: / L~aXLn~]ON:~a ~Z mo~: '2~& ~ Subdiv~ion: T~E OF WO~ ' ~: ' S~UA~ON: ~ Mulfi-~ily n Ad~n ' o Move ~ G~ * SF. ~ $ : ~F. - $ o ~ n Si~ ~ ~T~ V~UA~0N $ B~ DES~ON O~ ~ PRO~: ' ' E~ : ~0o~.~ 'j ' No. of Stofi~: ~ LotS~:~'%~.~~ Exis~g~ve~ge:~/~.~+~d~e: ~ /~.~=~T~TC0~GE: {~ /~.fi~ P~G USE O~Y: , ~pRov~ P~. Pe~i~ ~qu~d: N~t~: . M~. H~i~ $e~: ~g: DPW Site PI~ ~d Use App~ved by: · Da~: ES~etl~d(s): ~ Yes ~ No S~A ~i~ ~qu~? ~ Y~ ~ No ~e~ ~e Build~g Division c~ pmvid~ you wi~ mo~ d~iled ~fo~sfi0n on ~ application ~d pl~ ~bmi~ B~G PE~ ~P~CA~ON S~: Yo~ ~mpl~d ~p~o~ s~ p~ ({or ~om) ~ b~d~g ~on pl~ ~ W ~ ~bmi~ to ~e Bufl~g Division. VALUA~ON OF CON$I-~U~ON: h ~ ~, a ~on ~t m~ ~ ~ by ~e appli~L ~is fi~ will be mvi~ ~d may ~ ~ ~ ~e Bui~ Div. ~ ~ply w~ ~t ~ ~ul~. ~ ~e ~ ~a~ ~ 417~ 15 ~ ~. P~ ~ ~E: Yo~ plm ~ ~ is due ~ ~ ~e ~e ~ild~g pe~it a~li~on ~d ~n~on pl~ o~er pe~it fees ~ due~a ~e ~e of~t ~u~ce, . E~ON OF ~ ~W: If no ~t h ~ wi~ 180 days of~ da~ of appliCon, ~h appli~fion will ~i~ by l~imfiom. ~e BulldOg O~ci~ ~ ~d ~e ~e f~ a~ ~ ~e ~p~tup W 180 days, on ~n ~qu~ by Se~ion 107.4 of~e Unifo~ Bulldog ~e, ~t e~fion). No,applic~tio~ cm ~ ~t~ m~ ~m once. 1 ~eby ~ i~t I ~ ~ad ~ ~am~d ih5 ~pl~ation a~ ~ t~ same to be ~ a~ c~t, and I ~ for th~ p~mlt I u~r$t~ It ~ not ~ C~ legd r~o~iblli~ to.~t~ine wh~ ~mi~ ~ r~d; it ~ai~ r~po~ibiliW to d~t~mi~ w~t ~rmi~ ~ r~u~ ~ to ob~in ~ SITE PLAN DEPARTMENT OF PUBLIC WORK~, BUILDING D/VISION See Page 4for i~tructio~ on complezing ih~ si~ pla~ FOr more i~ormatio~, ~ 4574~11, ~bn 1~$. APPLICANT: /'"-, . {-~ L.~ /~ { PHONE: See Pa~e 4for inst~io~ on compl~ing t~ s~e pl~ For ~m i~o~io~ call 457-~11, e~em~n 125.~ ~2~ PAGI CITY OF PORT ANGELES PUBLIC WORKS - ELECTRICAL DIVISION ~21 EAST 5TH STREET. PORT ANGELES. WA 98362 ELECTRICAL PERMIT ISSUED: 6/14/2001 PERMIT NO 7299 OWNER/APPLICANT PROPERTY LOCATION LEE HUNT 904 PINE 904 PINE Lot: N1/2 1&2 Port Angeles, WA 98362 Block: 296 [] Long Legal 360/452-6500 Subdivision: TPA T: S: Parcel No: 063000029600000 CONTRACTOR ARCHITECT OWNER N/A VARIOUS Port Angeles, WA 99360 , 98360-0000 206/000-0000 360/000-0000 PROJECT INFO Project Type: MISC Project Value: $0.00 Occupancy Type: Construction Type: Occupancy Group: Zoning Use: Electrical Heat: [] Baseboard 0 KW [] Riser [] Underground Service [] Furnace 0 KW [] Overhead Service Voltage: 0 [] Heat Pump 0 KW [] TempService Phase: [] I [] 3 [] Fan Wall 0 KW Service Size: 0 Feeder Size: 0 PROJECT NOTES FEES ASSESSMENT Service: $0.00 Additional Feeders: $0.00 Circuit Wiring: $44.25 Temp Service: $0.00 Misc Fee: $0.00 TOTAL FEE: $44.25 AMOUNT PAID: $44.25 BALANCE DUE $0.00 ELECTRICAL PERMIT INSPECTION RECORD CALL 4174735 FOR ELECTRICAL INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL FO CO~3f~% INSULATE OR CONCEAL ANY WORK BEFORE IT IS INSPECTED AND ACCEPTED. KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE DITCH ROUGH-IN / COVER SERVICE GENERAL COMMENTS: CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS ........... INSPECTION REPORT ........... REQUEST: Date *"'~ '- I"'~--~:~ Timel(~: l-~:~,~v~ Received by ~"~ (phone, person) · Location of Work to be inspected (~(~)~'~ ~, Pt Name of person requesting inspection J-.~ ~.>//1 Address of person requesting inspection Phone No. Permit No. Type of Inspection (circle appropriate one): Sewer o~(~ati~n~ Framin'g Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: ~ //~ ~/~ Inspected: Date -? - / '~ - ~) / Time ~)/~t~ By Remarks: RESTORATION REQUIRED ...... YES. NO SURFACE RESTORATION: SURFACE TYPE: [] Unimproved [~Gravel [~]Asphalt F-]PCC [~Other _ [-I Repaired by City Work Order # ~] Repaired by Permittee ~ COMPLETE [] No Damage Found [] INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE) CITY OF PORT ANGELES DEPARTMENT OF PUBLIC WORKS ........... INSPECTION REPORT ........... REQUESTI ~ (phone, person) Date ~ ~ ' ' ~ Time Received by ~ ~, Location of Work to be inspected i '~/' '~ Name of person requesting inspection Address of person requesting inspection Phone No. Type of Inspection (circ!e~.~pp[,opriate one): Permit No. Sewer Foundation Framing,i Chimney Plumbing Final Sewer Excav. Other INSPECTION NOTES: Inspected: Date Time By Remarks: RESTORATION REQUIRED ...... YES. NO SURFACE RESTORATION: SURFACE TYPE: [] Unimproved []Gravel [~Asphalt []PCC ~Other [] Repaired by City Work Order # [] Repaired by Permittee [] COMPLETE [] No Damage Found [] INCOMPLETE (Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)