HomeMy WebLinkAbout612 S Chambers St - Engineering
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . . . . . . INSPECTION REPORT . . . . . . . . . . .
REQUEST. / ~
Date 5://6/11/ Time '-2-- ~ D-eJ Received by c;<
I I ~
Location of Work to be inspected h /7- S L!Iftt..H ~...s:
Name of person requesting inspection 'TJrzu c; .;?q,r-cl - /) El n ;<\ (~'d! ~or>
I
Address of person requesting inspection
Type of Inspection (circle appropriate one)
Sewer Foundation Framing Chimney Plumbing
!U+f;J8
(phone, person)
Phone No
C436
Permit No
Fina~er EXi9 Other
Inspected Date
Remarks
Time
,1 ; GD rJY1 BY~
RESTORATION REQUIRED. . .. YES X NO
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:;"7 (J!I",/- - ~"' 55' 0.0
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SURFACE RESTORATION. ( -3:(t
SURFACE TYPE D Unimproved D Gravel [EJ Asphalt D PCC
D Other
D Repaired by City
o Repaired by Permittee
o No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)
S
d/ .
~
.,.dUCANT/OWNER~ez. STRtJTCOI-! ADDRESS OF JOB: fa 12 S
APPUCANT ADDRESS: 0 n g GI1.!H.(MJfnONE tj57~25 LEGAL OF JOB:
PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ext. 124
PERMIT II \14 j 0
(] t-f AM 8e-tzs;
WORK IS [J OUTSIDE or [J INSIDE OF TRAVELED ROAD VALUE OF WORK IS:$ (If work is outside roadway
and is equal to or less than $2,000, then permit may be issued to other than licensed and bonded contractor.)
PLANS REQUIRED [J YES [J NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED [J YES 0 NO AMOUNT: $
PROOF OF INSURANCE: [J Worle $2,000 or leis: $50,000 personal injury, $100,000 per incident, $20,000 property
[J Worle OVer $2,000: $200,000 personal injury, $500,000 per incident, $100,000 property
[J Right of Way Use: $300,000 personal injury, $300,000 per incident, $100,000 property
Pennitteo understands that IlO atreet may be closed to traffic unless approved by the City Engineer and Chief of Police in advance of the
closure; that there is a 24 hour minimum notice prior to inspection, and to caU 48 hours before digging to: 1-800-424-5555.
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'fi.... .;~.._._. or ~.1bI proOall -* oI'ZIf MltklonXlUbla wdDr lb= lir;rm1 oI1b11 awl~ m:I \he pcrtWl or permil&..tDdro InI')' be pmIID(Iil._~
....oil .....;.~_......_ _. DATE: Si6 If b
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...................~................... 'i I ,m'D
FEE REO'D PAID TYPE FEE PAID
JJQHT OF WAY EXCAV. ....00 '10, 13() ~1~ER (SFIl) (IS" 10 PIl.., 6"1l.' 110,00
~-.OJ' SAN. SEWER /UFR.\. hi \dl 110.00
WOlII'TEJ< $125.00 SAN SEWER IUFR\. ADD. UNIT ".00
DOJVEWA Y '125m IAN sEWER. 0'TltD.S . MiI1..S1j.OO; SO.D)j11l
Ma-nSO 100 ax.tISQ.OO25 ex"","
r:NY CULVERY ....00 SEWER. TAP. IV CrTY ~O SI1S.to.'SJlXl.OO
WYElMANHOLE TAP
rnEEI' ctlf. ~ =.00 :Leo, lJO SEWER CAP/"NATER METER. S:W.OO
UMOVAL
OTHEIIJGHT OF Wit. Y WORK ...m ALTERATIONI C 1JO.00 :0 ;::::?/)
J.DAJR TO SEWD
---
FW!1lY1lOA1<r DEPOSrr STORM DIlA[N TAP 1123,00
lEI, "ATEll SEJ.V1CE '0 X SIlo $,55O.CO CATCH BASINS [N lOTS PEIl EACH ....00
US, "ATEl. SEJ.V1CE 10 X",," ,,,n.co SECONDAJlY SEWER ASSESS. ""10.00 III $61'.00 cw..udc
RES. WA~ 'X ,. ~.oo SEWERSYS,nEV.CHAJlGE S314.ooIEWM
COWM. WATEllID.V1CE 10 - Slp:.o MD..WAUKEE DR, SEWEll ASSESS, SIXl.oo/EWM
:~:-J~
"ATn 1D.V1CE. omn EmMATE RIOHT OF WAY USE PERMITS VARJESU.Sloo
"ATEI. SYS. DEY. CKAlOE S7Xl.oo IEWM Tar ALS I I '7.hl1J)igeJ
Tw..,uft.u...dII......__~ "&ruMdIlape.ftDI&.lOdolba_k~.wJorU.~aboor>ta.u.lIppUoati<m- Eadapemul if~IUbjocIIOIhc"'__o(lhc l~oon&inrd.tbcapptic:aU"" .
o Storm Drain
o Underground TelephonelElectrical ( 211
~ TOTALS $ :<.cfo - RECEIPT # Rz? ISSUED BY: (jZCJ{j
DATEr6,J~
INSPECTION FEEs $
WORK ORDER No.
PIV-0209.03 (121931
INSPECTOR'S COPY - WlIITE
APPUCA!oIT'S COPY. PINK
OFFICE COPY. CANARY
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