HomeMy WebLinkAbout1206 W 18th St - Building CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY ECONOMIC DEVELOPMENT BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number 12- 00000009 Date 1/09/12
Application pin number 015695
Property Address 1206 W 18TH ST REPORT SALES TAX
ASSESSOR PARCEL NUMBER: 06-30-00-0-4- 5300 -0000-
Application type description MECHANICAL APPL. PERMIT on your state excise tax form
Subdivision Name
Property Use to the City of Port Angeles
Property Zoning RS7 RESDNTL SINGLE FAMILY (Location Code 0502)
Application valuation 4286
Application desc
GAS FIREPLACE
Owner Contractor
PENDERGRASS PAUL A PELLET HEAT CO.
1206 W 18TH ST 230C EAST 1ST ST
PORT ANGELES WA 983637014 PORT ANGELES WA 98362
(360) 457 -4406
Permit MECHANICAL PERMIT
Additional desc GAS FIREPLACE /TANK SET /GAS LIN
Permit Fee 71.30 Plan Check Fee .00
Issue Date 1/09/12 Valuation 0
Expiration Date 7/07/12
Qty Unit Charge Per Extension
BASE FEE 50.00
1.00 10.6500 EA ME -STOVE /FIREPLACE /MISC. APP. 10.65
1.00 10.6500 EA ME -FUEL GAS PIPING,1 -5 OUTLETS 10.65 t
Fee summary Charged Paid ,Credited Due Q
Permit Fee Total 71.30 71.30 .00 .00
Plan Check Total .00 .00 .00 .00
Grand Total 71.30 71.30 .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•nofcommenced within 180 days, if construction or work is suspended or abandoned
for a 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
not presume to give authority to violate or cancel the provisions of any state or local law regulating construction or the performance of
construction.
troy Peoym jtm V.ewe
Date Print Name Signature of Contractor or Authorized Agent Signature of Owner (if owner is builder)
T:Forms /Building Division Building Permit
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 Date Accepted By Comments
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 FINAL Date Accepted by
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 1
Wood Stove Pellet Chimney
Commercial Hood Ducts FINAL Date(p'22' re Accepted bycilL
MANUFACTURED HOMES:
Footing Slab
Blocking Hold Downs
Skirting
PLANNING DEPT. Separate Permit tts SEPA:
Parking Lighting ESA:
Landscaping SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/ USE
'Inspection Type Date Accepted By
Electrical 417 -4735
Construction R.W. PW Engineering 417 -4831
Fire 417 -4653
Planning 417 -4750
Building 417 -4815
T:Forms /Building Division /Building Permit
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Jan. 5. 2012 1:43PM Spa Shop No. 9945 P. 1
BUILDING PLUMBING MECHANICAL PERMIT APPLICATION SHORT FORM
(To be used for projects that do not require plan review.)
Date Received
Permit# —o &5
City of Port Angeles Please print in ink. Date Approved
Attn: Building Permit Technician Approved by
321 E. 5 St., Port Angeles, WA 96362
360 -417 -4815 fax: 360 417 -4711 Credit card payments are accepted Mon -Fri 8 -5 pm (no American Express)
Hours: Mon through Fri 8 5 pm Cash checks are accepted Mon -Thurs 8:30 -4 pm Fri 8:30 -12:30 pm
Contact person: Phone:
P perty o ne
Pt P b G-RA Phone: V6/
Property owner's maili dress: is
9'3C3
O
Contractor's business name: SPA SHOP Pg 44 fr 14 Co, Phone:
(or property owner's name if he /she is doing /overseeing the work) 3 ,c» L 11
Contract is mailing address:
230 EAST rills PoRr Oivc E 1.,4)14._ St
Contractor's L &I license number: Expiration date:
GD O M -13 —1
Project Address: I 2,0 uu_
Project Type: Residential c D D Commercial ED Industrial iz Multi family
Project Business Name:
(for commercial, industrial, or multi family projects)
The following permits are usually issued over the counter immediately, without the need for plan review,
Complete only the portions of this permit that are relevant to your project.
Re -roof: house garage o other
d tear off re -roof lay over one layer
Licensed contractor: Submit a copy of your re -roof bid.
Project Valuation x (labor materials, not including sales tax)
Re -side: house garage o other
Project Valuation (labor materials, not including sales tax)
Repair: (explain the project)
Project Valuation
*Homeowner: If you will be doing overseeing the work, then the project valuation will be determined by doubling the
cost of materials, to reflect the value the repair adds to your property.
Cost of materials x 2 Project Valuation
T:Forms /Building Division /Bullding /Plumbing /Mechanical Permit Application Short Form (Revised 2011)
Pagelof2
Jan. 5. 2012 1:43PM Spa Shop No. 9945 P. 2
Swimming Pool or Spa 24" deep): For prefabricated swimming pool or spa projects that
do not require plan review:
Obtain the City of PA handout entitled "Pools Spas" follow the requirements.
Project Valuation
Demolition: A demolition permit is needed when an entire building gets demolished.
What will be demolished? o house a garage a other
Note: some demolition permit applications need to be reviewed by various City departments, and may take
approximately two weeks to obtain.
Agree to ensure that all utilities are /will be properly turned off (and capped off if needed)
prior to demolition.
Obtain (from the City of PA) an aerial view map of the parcel and put an "x" over the structure(s) to
be demolished. Submit the map with this application.
Obtain (from the City of PA) a copy of the Olympic Region Clean Air Agency (ORCAA)
Demolition Permit Application.
Contact ORCAA at 360- 417 -1466 to discuss whether or not an ORCAA Demolition Permit will also
be needed.
is yes o no Will the debris be going to the Regional Transfer Station in Angeles?
o yes o No If yes, will a licensed contractor be taking it there?
If yes, obtain (from the City of PA) a copy of the Waste Disposal Application,
Complete and submit the waste disposal application Co the Building Permit Technician, now
(or later if asbestos testing is needed):
Plumbing Permit: (explain the project)
Project Valuation
Mechanical Permit: (explain the project)
S&RfeKL PitoP4NE 790)(.
r.
Fl(.Pt'?-c4. INs =;7op)
Project Valu ation
I have read and completed this application and know it to be true and correct. I em authorized to apply for this permit
and, understand that it is my responsibility to determine what permits are required, and to obtain permits prior to
working on projects.
Date 2- Signature e—
Print Name �6 rAreS r oizb
Page 2 of 2
SPA SHOP
Pellet Heat Company
Spas, Pellet Gas Stoves
Where Quality Customer Service am #1
230-C East First St., Port Angeles, WA 98362
(360) 457 1
www.spashop.com
STOVE: A-- )1- Co
z 2., z_
STOVE BRAND Aledde4A MODEL DL s 6-As
SHROUD SIZE GCLUaR 14 3
PIPE: Rib
QTY. DESCRIPTION
A -1/ 00377 yx
Ydi
D 4 /6 OVAYcg 14^ C AP If 7
A14 II- 6.077q A rel., /Ai e
AA e
I t 6 1 :4
0 36-
HEARTH PAD: 3b/
PAD SIZE/COLOR:
ACCESSORIES/OTHER:
ITEM
ITEM 3it 1 pp re.,
i
PELLETS:
QTY./BRAND
INSTALLATION:
STOVE INSTALLATION 3.5-13.aa
REMOVAL OF WOOD STOVE
COMMENTS/INSTRUCTIONS: MDSE. SUB-TOTAL
PERMIT FEE
ck.,1.- --"r SALES TAX 320,
SUB-TOTAL s
j O»i t="1/
WA STATE STOVE TAX
TOTAL 1 7")
DEPOSIT
BALANCE DUE
DEALER 04-1- CUSTOMER
DATE Z z. 3 --/d APPROXIMATE DELIVERY DATE cuak... c" 1 2.— Z2. or Plej
NAME Pi4tk_ 1 A R(
ADDRESS .J.,aa,
CITY/STATE/ZIP POP-T /IL C3 1
PHONE: HOME 1-/(,i iJ WORK #A.No- 39,3
Thank vou! SPA SHOP 8I3
CITY OF PORT ANGELES
t DEPARTMENT OF COMMUNITY ECONOMIC DEVELOPMENT BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
Application Number 12- 00000463 Date 4/23/12
Application pin number 872605
Property Address 1206 W 18TH ST
ASSESSOR PARCEL NUMBER: 06- 30- 00 -0 -4 -5300 -0000- REPORT SALES TAX
Application type description RE -ROOF on your state excise tax form
Subdivision Name
Property Use to the City of. Port Angeles
Property Zoning RS7 RESDNTL SINGLE FAMILY (Location Code O$O2)
Application valuation 1400
Application desc
REROOF NORTH SIDE OF HOUSE
Owner Contractor
PENDERGRASS PAUL A LARRY' S. ROOFING
1206 W 18TH ST 352 AVIS ST.
PORT ANGELES WA 983637014 PORT ANGELES WA 98362
(360) 452 -2215
Permit BUILDING PERMIT NO PR FEE
Additional desc REROOF NORTH SIDE OF HOUSE
Permit Fee 77.45 Plan Check Fee .00
Issue Date 4/23/12 Valuation 1400
Expiration Date 10/20/12
Qty Unit Charge Per Extension
BASE FEE 50.00
9.00 3.0500 HND BL- 501 -2K (3.05 PER C) 27.45
Other Fees STATE SURCHARGE 4.50
Fee summary Charged Paid Credited Due
Permit Fee Total 77.45 77.45 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.50 4.50 .00 .00
Grand Total 81.95 81.95' .00 .00
hriraA Lt•25
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 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 kn• the same to be true and correct. All provisions
of laws and ordinances governing this type of work will be complied with wh- er spec ifie. ∎erein or not. The granting of a permit does
not presume to give authority to violate or c el the provisions of any stet,- loc e; ulating construction or the performance of
construction.
1 4 4- "?2 I a I/
OM 6azS A\
Date Print Name Signature of Contractor or Authorized Agent Signature of Owner (if owner is builder)
T:Forms /Building Division /Building Permit
BUILDING PERMIT INSPECTION RECORD
0
PLEASE PROVIDE A MINIMUM 24 -HOUR NOTICE FOR INSPECTIONS S
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. .i
Inspection Type Date Accepted By Comments
FOUNDATION: n
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 FINAL Date Accepted by
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 Fumace FAU Ducts
Rough -In
Gas Line
Wood Stove Pellet Chimney
Commercial Hood Ducts FINAL Date Accepted by
MANUFACTURED HOMES:
Footing Slab
Blocking Hold Downs
Skirting
PLANNING DEPT. Separate Permit #s SEPA:
Parking Lighting ESA:
Landscaping SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/ USE
Inspection Type Date Accepted By w
1
Electrical 417 -4735
Construction R.W. PW Engineering 417 -4831
Fire 417 -4653
Planning 417 -4750 V`'
Building 417 -4815 2.G.
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i�.rORrq,tC BUILDING PERMIT APPLICATION Print in ink
A. CITY OF PORT ANGELES
sY A ttn: Building Permit Technician For City Use Only:
Date Received -I Zz -tZ
1 .-:asimar 321 E. Fifth St., Port Angeles, WA 98362 Permit 7-z �s✓ j
NOW (360) 417 -4815 fax (360) 417 4711 Date Approved 4
Applicant Ado r Phone
Property Owner w %Wet- S Phone
Property Owner's Add/es (0. (8
Contractor 491,1s 1A5 K Phone
Contractor's Address "I (j r r6.�
License Expires E -mail
PROJECT ADDRESS 17.06 60 i84
Parcel Number Lot Zoning
Project Type Brief Description: 'Residential Multi family Commercial a Industrial
Check all that apply
New Construction
❑Addition Q 4 C IQCt, Qh iV
b i or
Remodel LeAr
o Rep
Demolition
Re-roof A House garage o other X tear off re -roof lay over one layer
a Heat System o Heat pump a wood- burning stove o gas fireplace o pellet stove o other
o Other
Floor Areas Existing (sq. ft.) Proposed (sq. ft.)
Basement per sq. ft.
l Floor
2 Floor
V Floor
Garage
Carport
Covered Porch
Deck
Shed
Other
TOTAL VALUATION POO
Total footprint of structures sq. ft. T Lot size sq. ft, Lot coverage
Site Coverage the amount of impervious surface on a parcel, including structures, paved driveways, sidewalks, patios,
and other impervious surfaces. (see PAMC 17.94.135 for exemptions) Site coverage
Max. height of proposed structures ft. Occupancy group of bedrooms
Will a lawn sprinkler system be installed? Occupant load of full baths
Will a fire sprinkler system be installed? Construction type of half baths
I have road and completed this application and w it to be t r u e and correct. 1 am authorized c I r this permit and understand
that it Is my responsibility to datermine y pe it re requirod, and to obtain permits prior to irking!, .,.jects.
Date 4 -12_ Pnt Name 143-11\ be,' Signature 1 N
T:Forms /Building Division /Building permit application
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORt ANGELES, WA 98362
BUILDING PERMIT ISSUED: 12/05/2002 PERMIT NO: 13896
OWNER/APPLICANT PROPERTY LOCATION
PAUL PENDERGRASS 1206 18TH ST W
1206 W. 18TH STREET Lot: 1&2
Port Angeles, WA 98363 ,, Block:, 453 [] Long Legal
360/808-4864 Subdivision: TPA
T: S: Parcel No: 063000045300000
CONTRACTOR ARCHITECT
OWNER N/A
VARIOUS
Port Angeles, WA 99360 , 98360-0000
206/000-0000 360/000-0000
PROJECT INFO
Project Value: $3,500.00 SFD Units: 0 Commercial: 0
Project Type: REMODEL 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
NEW ROOF, EXTEND EXISTING BATHROOM
RECEIPT#9982
FEES ASSESSMENT
Building Permit: $97.25 Misc Fee 1: $0.00
Plan Check: $0.00 Misc Fee 2: $0.00
State Surcharge: $4.50 Misc Fee 3: $0.00
House Moving: $0.00
Manufactured Home: $0.00
Sign: $0.00 TOTAL FEE: $135.75
Plumbing: $34.00 AMOUNT PAID: $135.75
Mechanical: $0.00
BALANCE DUE: $0.00
Radon: $0.00
SeparatePermitsarerequiredforelectricalwork, SEPA, Shoreline ESA utilities privateandpub c mprovements Thspermitbecomesl
null and void if work or construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned
[or a period of 180 days after the work as commenced, or if required inspect ons 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 o!
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 at~ta~_or local law regulating construction or the performance of
Signature of Contractor or Authorized Agent Date Signature of Owner (if owner is builder) Date
T:\PLANNING\FORMS\ 1102.15 [4/2002]
BUILDING PERMIT INSPECTION RECORD . .
CALL 417-4815 FOR BUILDING INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. ITIS UNLAWFUL TO COVER,
INSULATE OR CONCEAL ANY WORK BEFORE INSPECTED AND ACCEPTED. POST PERMIT IN A CONSPICUOUS LOCATION.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE ,~ ~77 ~
INSPECTION TYPE I DATE IYEsACCEPTED,Ii NO COMMENTS'
FOUNDATION:
FOOTINGS
WALLS
FOUNDATION DRAINAGE
ELECTRICAL (LIGHT DEFT) SEPARATE PERMIT: #
PLUMBING
~oER FLOOB / SLAB
WATER LINE
GAS LINE
BACK FLOW / WATER
AIR SEAL
FRAMING
JOISTS / GIRDERS
SHEAR WALL
WALLS,ROOF' EILINO > fl
DEYWALL
MECDANICAL
HEAT PUMP
WOOD STOVE / PELLET / CH/MNEY
HOOD / DUCTS
PW UTILITIES / SITE WORK (Engineering Division) SEPARATE PERMIT #'s:
WATERLINE / METER
SEWER CONNECTION
SANITARY
STORM
PLANNING DEPT. SEPARATE PERMIT#'s SEPA:
PARKING/LIGHTING ESA:
LANDSCAPING SHOBELINE:
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
FIRE 417-4653 ¢ FIRE DEPT.
PLANNING DEPT. 417-47,0 in,, ~ '. . /~ BUILDINGPLA]~NIN~ DEPT'
Date Approved:
The Building Pe~it Application must be~lled out completely. Date Issue:
Please type or print in ink. If you have any questions, please call 417~815
O~er: ~ffi~ Phone: ~
~chitecUEngincer: Phone: -
Contractor License ~:" Exp:[ Phone~
Address: " City:. Zip:.
L[aAL ~escm~xxos: Lot: I * ~ Block:~ Sub.vision:
CL~L~ CO~TY P~CEL N~BER:~redit Card Holder Name:
mning~adress: S~& ~ ~O~ City:
Credit Card 8: Exp. Date: ~SA MC
eEOF WO~: SIZE~UATION:
sid~tial ~ NewCons~. ~Re-roof D Wood-stove ~,~ SF.~$ ~0 /SF.=S
~ Mulfi-fa~ly D Addition D Move ~ G~age SF. ~ $ /SF. = $
~ Co~ercial ~ Remodel ~ Demolition ~ Deck SF. ~ $ /SF. =
~ Repak ~ Sign ~ TOTAL VALUATION $ ] 0, ~, 00
BmEFDESC~TIONOFT~PROJECT: ~lO 6~ ~ ~X~ ~0
COMMERCI~S~ENT~: Occupancy G~oup:. Occupant Load: __ Cons~cfion T~e:
No. of Stories:~ Lot Size: % Lot Coverage: %.
Existing Lot Coverage: /sq. R. + Proposed Lot Coverage: /sq. ~. = TOT~ LOT COVE~GE: /sq.
PLYING USE O~Y: . ~PROV~S: PL~
Notes: BLDG.
DPW
ES~etland(s): ~ Yes ~ No SEPA ~ecklist requked? ~ Yes ~ No O~er: OTHER
B~LDING PE~T ~PLICA~ON S~: Your application and site plan must be fdled out completely to be accepted fo;
r~iew. The Building Division can provide you wi~ more detailed ~fo~tion on ~e application ~d pl~ sub~l requffe~nts. Yo~
co~leted application, site plan (for additions) and building co~ction pla~ are to be sub,Red to the Building Division.
V~UATION OF CONSTRUCTION: In all eases, a valuation amount must be entered by the applicant. ~s figure will be reviewed
~d ~y be revised by ~e Bulldog Division to co~ly with c~ent fee schedules. Contact the Pe~t Coordinator at 417-4815 for assistant.
PL~ CHECK ~E: Yo~ plan check fee is due at ~e time ~e bmlding pemt application and cons~ction plato are subdued. All other
pe~t fees ~e due at the time ofpe~t issuance.
EXPIATION OF PL~ ~V~W: If no pemt is issued wi~m 180 days of~e date of application, ~s applica~on will expire.
Bulldog Official can extend ~e t~e for action by the applic~t up to 180 days upon ~en request by the applicant (see Section 107.4 of
the Unifo~ Building Code, c~ent edition). No application can be extended more than once.
[ hereby cert~ that I have read and examined this application and ~ow the same to be ~e and correct, and I am authorized to apply for
this permit, l understand it is not the Ci~'s legal respo~ibili~ to determine what pemits are required; it remains the applicant's
responsibili~ to determine what permits are required and to~_
SITE PLAN
DEPARTMENT OF PUBLIC WORKS, BUILDIN~ DIVISION
'pRoJECT/DEVELOPMENTADDRESS:~ I~0(0 '"~AJ. {~::~ ~T'~
See Page 4 for instructions on completing the site plan. For more information, ca11417-4815.
ITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
........... INSPECTION REPORT ...........
REQUEST:/~ '- .~'-- ~ '-~
Date _ Time Received by (phone, person)
Location of Work to be inspected ~ ~ (~ & ~/('
Name of person requesting inspection
Address of person requesting inspection Phone No.
Type of Inspection (circ!.e_app.r~riate one):/~ Permit No../~'~.~'~*~
Sewer Foundatlor~, Framing/Chimney ~Plumbing~ Final Sewer Excav. Other
INSPECTION NOTES:
Inspected: Date ~ ~-~ - ~'-(~ '7_~ Time By
\
Remarks:.
RESTORATION REQUIRED ...... YES NO
SURFACE RESTORATION:
SURFACE TYPE: [] Unimproved []Gravel r--[Asphalt [-'~PCC [~Other
[] Repaired by City Work Order #
I--] 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 ...........
REQUEST:
Date /~//~/~ ~ Time / ~ ~ Received by ~ ~-~ (phone, p~S0~,i
Location of Work to be inspected [~'~, , g~-P ~..y~'/''
Name of person requesting inspection ~/~?~.~ ? ~ ~, .~ c ~ ~ ~i n .5/' (~ ~ %
Address of person requesting inspection Y Phone No.
Type of Inspection (circle appropriate one): Permit No.
Sewer Foundation Framing Chimney Plumbin~l?Fina~
Sewer Excav.
Other
INSPECTION NOTES:.
Inspected: Date h~ll~t/""z~l~'II '~' Time ~{, By ~_ ~
Remarks:
RESTORATION REQUIRED ...... YES NO
SURFACE RESTORATION:
SURFACE TYPE: [] Unimproved l-]Gravel I--IAsphalt ~IPCC [~Other
[] Repaired by City Work Order #
[] Repaired by Permittee [] COMPLETE
[] No Damage Found [] INCOMPLETE
(Continue on reverse side if necessary) STREET SUPERINTENDENT (DATE)