HomeMy WebLinkAbout415 S H St - Building
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CITY OF PORT ANGELES s 'IH II
PUBLIC WORKS "BUILDING DNISION 41 c..
321 EAST 5TI1 STREET, PORT ANGELES, WA 98362 r ./
PUB/LlC WORKS & R/W PERMIT
o Attached Notes
OWNERIAPPLlCANT
Brenda Nance
415 South "H" Street
Port Angeles, WA 98363
000/604-7354
PROJECT INFO
Work is:
Plans Required:
Contractor: OWNER
Performance Bond Required:
Proof of Insurance:
Work to Perform:
Issued:
6/07/2001
Permit No:
Work Order:
PROPERTY LOCATION
415 HSTS
Lot:
Subdivision:
Parcel No:
1171
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tpa
Block: 122
D Long Legal
Start Date:
Amount:
D Install
D Repair
D Watermain
Value Work:
$0.00
II
Finish Date:
206/000-0000
$0.00
D Sanitary Sewer
D Storm Drain
D Underground Tele/Elec
PROJECT NOTES
REMOVE TREE FROM CITY RIGHT OF WAY
~ Mise
II
remove tree
FEES ASSESSMENT
1.) RIW Excav: .
2.) Sidewalk:
3.) Curb/Gutter:
4.) Driveway:
5.) Dwy Culvert:
6.) Street Cut:
7.) Other RIW:
8.) Fire Hydrant:
9.) Res Water Serv:
10.) Comm Water Serv:
11.) Other Water Service:
12.)Water System Dev:
13.) San Sewer SFR:
14.) San Sewer MFR:
add unit: 0
$45.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
. Receipt No:
Inspection Fee:
RW SANITARY
$0.00
WATER
15.) Other San Sewer:
16.) Sew Tap WyelMan Tap:
17.) Sew Capl WIM Removai:
18.) Alter Repair Sewer:
19.) Storm Drain:
20.) Catch Basin per ea:
21.) Sewer System Dev:
22.) Milwaukee Dr. Sew Ass:
23.) RIW Use Perm:
24.) Admin Cost (D.R.A)
25.) D.R.A.
26.) Mise:
TOTAL FEE:
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$45.00
Amount Paid:
$45.00
. Balance Due:
DWY STORM
DRA
$0,00
OTHER
Separate Permits are required for electrical work, utilities, private and public improvements. This perm~ becomes null and void ff work (
construction authorized is not commenced ~in 180 days, if construction or work is suspended or abandoned for a period of 180 days aft.
the work as commenced, or ff required inspections have not been requested ~in 180 days from the last inspection. I hereby certify that I hav
read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of war
will be complied with whether specified herein or not. The granting of a perm~ does not presume to give authority to violate or cancel th
provisions of any state or local law regulating construction or the performance of construction.
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Si nature of Contractor or Authorized A ent" Date Si nature of Owner ff owner is builder Date
-------------.. -
.
HOLD HARMLESS AND
WAIVER OF LIABILITY AGREEMENT
Name: ~ <>-c<.t-.J_u- f\a--t--...'--~ Date: ro ~<f/O (
r .
Address: ~ \ '> ~ I+- Phone: 1-:;:t7 - ~'i'S1 In
consideration of approval of the following described work at:
...s; fJ 5+
for the purpose of: -1- rV-Q..
11>
Y?~n....J!
the undersigned on behalf of the property owners and their heirs
and assigns, hereby agrees to defend, indemnifY, and hold the City of Port Angeles and its officials,
employees and agents, harmless against any claims and/or lawsuits for personal injury and/or
property damage arising out of, or in any way connected with, the above described proposal except
for injuries or damages caused by the sole negligence ofthe City.
Dated this 1
day of Ju..I'-L
200 I
-'
~O- ()O<U-
(Signature)
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SUBSCRIBED and sworn to me this -L. day of ;;>'/ J --?'U'
2001
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I
NOTARY PUBLIC in for the State of
. ,Washington,residing'nrPorr-Angeles.
'My Commission expires{X" ;;y:fl~) Y
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