HomeMy WebLinkAbout937 Benjamin Ave - Engineering
.S
~~
CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DNISION
321 EAST 5TII STREET, PORT ANGELES, WA 98362
/..
PUBLIC WORKS CONSTRUCTION Issued: 10/16/96 LEH Permit No: 542
& R/W PERMIT Cond: Work Order: 0
OWNER/APPLICANT------------------------PROPERTY LOCATION------------------------
MICHELE JOAQUIN 937 BENJAMIN AVE
937 BENJAMIN Lot: 5
Port Angeles,WA98362 Block: Long Legal:
360/457-7207 Sub: PINEBROOK #1
PROJECT INFO------------------------------------________________________________
Work is OUTSIDE traveled road Value Work: $O.OO~
'-N
~
~
Plans Required: N/A
Contractor:
Start:
Finish:
Performance Bond Required: N/A
Proof Insurance:
Storm Drain
Underground Tele/Ele
Misc
NOTES--------------------------------___________________________________
Work to Perform:
PROJECT
Amount:
Watermain
Sanitary Sewer
/
/
/
/
$0.00
PROJECT FEES ASSESSMENT--------------------------------_________________________
R/W Excav: *
Sidewalk:
Curb/Gutter:
Driveway:
Dwy Culvert:
Street Cut:
Other R/W:
Fire Hydrant:
Res Water Serv:
5/8"
3/4"
1"
Corom Water Serv:
1"
1 1/2"
2"
Oth Water Serv:
Water Sys Dev:
Receipt No:
Inspection Fee:
R!W
SANITARY
$40.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
San Sewer SFR:
San Sewer MFR:
Add Unit: 0
Other San Sewer:
Sew Tap Wye/Man Tap:
Sew Cap/ W/M Removal:
Alter/Repair Sewer:
Storm Drain Tap:
Catch Basin per ea:
Sewer System Dev:
Milwaukee Dr. Sew Assess:
R/W Use Perm:
D.R.A. :
Admin Costs (D.R.A):
Misc:
$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
$0.00
$0.00
$0.00
------------------------------
------------------------------
$40.00
$40.00
BAL DUE:
-----------------------
$0.00
Si nature of Contractor or Authorized A ent Date
$0.00
TOTAL FEE:
AMT PAID:
$0.00
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
provisions of any state or local law regulating construction or the performance f construction. rl
let fL 7tZ'
NAME OF APPLICANT
MAILING ADDRESS OF APPLICANT
PHONE NUMBER OF APPLICANT
STREET ADDRESS FOR STREET USE
D RIGHT OF \N A V USE PERMIT 0
/VJ/(, ilL Lt
~T C tcq I J ) II
11::;7 J~fn1{,( m/(\
IJ~ 7.. 7 -:}-r}7
0; "2.)) f)e .rV}t/i fYl, ()
,
DATE
! (;' I (y t/ [fi
Al/f,
A..v.{
DESCRIPTION OF TIlE REQUEST (include drawings for clarity) (If street closure is requested, please
st~e name of street and limits of closu;re requested together with the duration of closure.)
\ I, I '1 '\ 1", r ' 1 11 I , 1', I I ' I.) . I, 1'1., {( ~
I . .' I , . {. . '" '., ". '" I, 'l , \ . \ /, VI, I a I .,1 I
~~~' ~URAT~~N '':;;''T ~~~~JroN WILL BE' IN PLACE (i. e.. hours 0 f operation) AND HOW IT
WILL BE LIGHTED:
1/, }
Vi I
EXPLAIN NECESSITY TO USE THE PUBLIC STREET, SIDEWALK OR PLANTING ST&IP:
_ -nJ
(L itl/II
/'l I' , .., I n
/1'(iJvvV JLnt1....'
I v r
+n ()f(tV(f1 If 'if{ I fI
* * * HOLD HARMLESS AGREEMENT * * *
In compliance with the Port Angeles Municipal Code, and in consideration of the issuance
by the City of Port Angeles of a Street Use Permit to the undersigned allowing the place-
ment of the above described street use, the undersigned for himself and for his successors
and interest, hereby agrees to save and to defend the City from, and hold the City harmless
against any claims or lawsuits for personal injury or property damage arising out of, or
in any way connected with the above described street use, except for injuries or damages
caused by the sole negligence of the City of Port Angeles or its agents.
DATED this
I!;r)~
IC
day of C (1ft) ti/\
, 19 q ( j
SUBSCRIBED an
this
State of
Angeles
any time.)
ARY PUBLIC in and for t
Washington residing at Por
by the City without cause and at
(Office Use Only) * * * * * * * * * *
Fee paid $ Receipt #
Agreement to Remove Encroachment
signed and recorded
Copies sent to: Police 0 Fire 0 Planning 0 Admin. Services 0 Date
Application approved/denied by Director of Public Works
(This permit, if
Date application received
Certificate of Insurance provided
COpy TO
APPLICANT 0
with conditions:
FIRE 0
POLICE 0
STREET 0
OTHER
o
FILE BY ADDRESS 0
RUP 0
RUP'~ #
......
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . INSPECTION REPORT.
.
REQUEST
Date /0-8-'7&.>
R .~ {PhOne,€~
Location of Work to be inspected '9-37 e~~/N Sr:-
Name of person requesting inspection ,-7:E ,pF ;::J ~ U I A/
Address of person requesting inspection c..::r ~ ".:::- Phone No ~-7- 7 ~ 7
Type of Inspection (circle appropriate one) Permit No ,~ <p
Sewer Foundation Framing Chimney Plumbing Final Sewer Excav Other P/~Hk
~e:.~.e:R ~ /"l'J..7;./sl?i-et:.-. Q~P r'V/Yir ~ ~~~ O~^'.
O~t$.- 6LP ~~ tf... ~trS~/i!>LC ~~s.
INSPECTION NOTES Re-'7T--'/!-I TO ~ J~.s-~ ~ O~E.
- -
Inspected Date /0 - 9 - 9 ~ Time By
Remarks
Time /0,' / ~
Received by
RESTORATION REQUIRED .. . YES NO
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, \).
t, ~
V
v
/
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,
(,
lJ
...
tJ
t:
~ /~
,
-;z"f"tJc.. ,f..'-e.,SI.C-.... L,,,,e
7l ~B
~
/"b '
'" .e,~"c1 .~'",,,...L
\
I ___ t, '7 I -----t>j
SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel 0 Asphalt 0 PCC
o Other
D Repaired by City
[] Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
t!)
~
CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
PUBLIC WORKS CONSTRUCTION Issued: 10/16/96 LEH Permit No: 542
& R/W PERMIT Cond: Work Order: 0
OWNER/APPLICANT------------------------PROPERTY LOCATION------------------------
MICHELE JOAQUIN 937 BENJAMIN AVE
937 BENJAMIN Lot: 5
Port Angeles,WA98362 Block: Long Legal:
360/457-7207 Sub: PINEBROOK #1
PROJECT INFO--------------------------------------------------------------------
Work is OUTSIDE traveled road Value Work: $0.00
Plans Required: N/A
Contractor:
Start:
Finish:
Performance Bond Required: N/A
Proof Insurance:
Amount:
Work to Perform:
Watermain
Sanitary Sewer
storm Drain
Underground Tele/Ele
Misc
NOTES-------------------------------------------------------------------
PROJECT
/ /
/ /
$0.00
PROJECT FEES ASSESSMENT---------------------------------------------------------
R/W Excav: *
Sidewalk:
Curb/Gutter:
Driveway:
Dwy Culvert:
Street Cut:
Other R/W:
Fire Hydrant:
Res Water Serv:
5/8"
3/4"
1"
Comm Water Serv:
1"
1 1/2"
2"
Oth Water Serv:
Water Sys Dev:
$40.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
San Sewer SFR:
San Sewer MFR:
Add unit: 0
Other San Sewer:
Sew Tap Wye/Man Tap:
Sew Cap/ W/M Removal:
Alter/Repair Sewer:
Storm Drain Tap:
Catch Basin per ea:
Sewer System Dev:
Milwaukee Dr. Sew Assess:
R/W Use Perm:
D.R.A. :
Admin Costs (D.R.A):
Misc:
$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
$0.00
$0.00
------------------------------
------------------------------
$0.00
$0.00
TOTAL FEE:
AMT PAID:
Receipt No:
Inspection Fee:
$0.00
WATER
BAL DUE:
R/W
SANITARY
DWY
STORM
DRA
OTHER
$40.00
$40.00
$0.00
Separate Permits are required for electrical work, utilities, private and public improvements. This permrt becomes null and void ~ work or
construction authorized is not commenced within 180 days, ~ construction or work is suspended or abandoned for a period of 180 days after
the work as commenced, or ~ required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have
read and examined this applicaton 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 permrt 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.
Sianature of Owner m owner is builder)
Date
Sionature of Contractor or Authorized Agent
Date