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CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DMSION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
PUBILle WORKS & R/W PERMIT
o Attached Notes
OWNER/APPLICANT
DANA SHAL TRY
Issued
10/11/2001
Permit No.
Work Order'
1208
o
PROPERTY LOCATION
611 8TH ST E
Lot: 12,13
Subdivision. TPA
Parcel No
Block. 226
Port Angeles, W A 98362
000/604-7491
PROJECT INFO
Work is
Plans Required
Contractor" R J SERVICES
Performance Bond Required
Proof of Insurance
Work to Perform
IZI Long Legal
Value Work.
$000
Start Date
1 1
Finish Date.
360/457-1420
1 1
Amount:
$000
D Install
IZI Repair
D Watermain
IZI Sanitary Sewer
IZI Storm Drain
D Underground Tele/Elec
D Mise
PROJECT NOTES
replace existing san sewer
FEES ASSESSMEN'f
1 ) R/W Excav' $45 00 15 ) Other San Sewer' $000
2.) Sidewalk. $000 16) Sew Tap Wye/Man Tap $000
3 ) Curb/Gutter' $000 17) Sew Capl W/M Removal $000
4 ) Driveway' $000 18 ) Alter Repair Sewer' $000
5 ) Dwy Culvert: $000 19 ) Storm Drain $000
6 ) Street Cut: $000 20) Catch Basin per ea. $000
7 ) Other R/W $000 21 ) Sewer System Dev' $000
8 ) Fire Hydrant: $000 22.) Milwaukee Dr Sew Ass. $000
9) Res Water Servo $000 23 ) R/W Use Perm $000
10) Comm Water Servo $000 24 ) Admin Cost (0 RA) $000
11 ) Other Water Service $000 25 ) 0 RA. $000
12.)Water System Dev' $000 26 ) Mise: $000
13 ) San Sewer SFR: $000 TOTAL FEE. $45.00
14 ) San Sewer MFR $000
add unit: 0 Amount Paid $45 00
Receipt No.
Inspection Fee $0.00 Balance Due $0.00
RW SANITARY WATER DWY STORM DRA OTHER
Separate Permits are required for electrical work, 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
provisO ns 0 state local law regulating construction or the performance of construction.
Si nature of Owner if owner is builder Date
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . . . .
J'? J1 /
REQUES~ It
Date '/ {) /
.
Time
!C
Received by -;-F-
(phone, person)
location of Work to be inspected
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one)
~~Foundation Framing Chimney
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/
Phone No
1Z,08
Permit No
Plumbing Final
Sewer Excav
Other
INSPECTION NOTES
Inspected Date p )/ jp I
Remarks
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Time By
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RESTORATION REQUIRED
YES
NO
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SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel 0 Asphalt 0 PCC
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C.O 0-'.5 l'
o Other
[] Repaired by City
[] Repaired by Permittee
[] No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)