HomeMy WebLinkAbout1602 W 12th St - Engineering
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CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DNISION
321 EAST 5TH STREET, PORT ANGELES, WA 98362
PUBILlC WORKS & R/W PERMIT
D Attached Notes
OWNER/APPLICANT
City of Port Angeles
Issued: 12/29/2003
Permit No:
Work Order:
1392
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PROPERTY LOCATION
1602 12TH ST W
Lot:
Subdivision: TPA
Parcel No:
Block: . 364
Port Angeles, WA 98362
000/600-0000
PROJECT INFO
. Work is:
D Long Legal
Value Work:
$0.00
Plans Required: Start Date: 1 1 fiinish Dat~: ' 1 1
Contractor: QWEST COMMUNICATIONS ,360/000-0000
Performance Bond Required: Amount: $0.00
Proof of Insurance:
Work to Perform: [gJ Install D Sanitary Sewer D Misc
[gJ Repair D Storm Drain I
o Watermain [gJ Underground Teie/Elec
PROJECT NOTES
replace 859' +/- section of defective buried cable in the 12113
alley right of way extending from 12/13 alley @ "I" Street
to apprOXimately 300' west of "K" St. Alley right of way width
is 20'.
FEES ASSESSMEN"F
1.) R/W Excav: $0.00 15.) Other San Sewer: $0.00
2.) Sidewalk: $0.00 16.) Sew Tap Wye/Man'Tap: $0.00
3.) Curb/Gutter: $0.00 17.) Sew Capl W/M Removal: $0.00
4.) Driveway: $0.00 18.) Alter Repair Sewer: $0.00
5.) Dwy Culvert: $0.00 19.) Storm Drain: $0.00
6.) Street Cut: $0.00 20.) Catch Basin per ea: $0.00
7.) Other R/W: $0.00 21.) Sewer System Dev: $0.00
8.) Fire Hydrant: $0.00 22.) Miiwaukee Dr. Sew Ass: $0.00
9.) Res Water Serv: $0.00 23.) R/W Use Perm: $0.00
10.) Comm Water Serv: $0.00 24.) Admin Cost (D.R.A) $0.00
11.) Other Water Service: $0.00 25.) D .R.A. $0.00
12.)WaterSystem Dev: $0.00 26.) Misc: $0.00
13.) San Sewer SFR: $0.00 TOTAL FEE: $0.00
14.) San Sewer MFR: $0.00
. add unit 0 Amount Paid: $0.00
Receipt No:
Inspection Fee: $0.00 Balance Due: $0.00
RW SANITARY WATER OWY STORM ORA OTHER
Separate Permits are required for electrical work, utilities, private and public improvements. This permit becomes null and void ifwork or
construction authorized is not commenced within 180 days, if construction or work is suspended or abandoned for a period of 180 days after
the work as commenced, or W required inspections have not been requested within 180 days from the last inspection. I hereby certify that I have
read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work
will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any state or local law regulating construction or the performance of construction.
Signature of Contractor or Authorized Aaent
Sianature of Owner lif owner is builder)
Date
Date
12-22-03; 3:31PM;
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2 03/DEC/19/FRI 03: 43 PM',j,f CITY OF PA BLDG DEPT
FAX No. 360 417 4711
P.001/00l
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P~R'fANGELB5
w A 51 H I J\l G TON. U. S. A.
NAME O~ APPUCANT (f{ /A;<-t' y-j- DATE
MAILING f\DpRESS~ Q/\v; Z (.I' ~ '7 N.;) t(,te/vid~ '~,
PHONENU~BER' \ r "LlO 4/7 - 'ZI , '
STREb JD9RE~~ O~PRO OSED STREET USE ' /2-/ -J; fk {tty.,U /.;U//J IE "Sf:zt.Lf
d\:SCbPPON OF RE' UEST (include drawings required for clarity): [If street closure is requested; please state the n<lme
elf the stre~t ' d limits' 01 sure. ' gether with e duration 0 closure.}.' A" ' / _ " '
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f ~ r "/, "rs'THEU$~ TEMPbAAR dR PERMANENT?' '.fl-.:..r IIz4 ,1 /I,i.L~c
HOW LONG Wl,ll THE OBSTRUCTION BE IN PLACE? ..J _
WHATARETHEHOURS OF OPERATION? Y - i7 ~A,/.,.)
HOW ITWllL BE LIGHTED?
EXPLAIN THE NECESSITY TO USE THE PUBLIC STREET. SJDEWAlKOR PLANTING STRIP. . ARE THERE
ALTENA~S THAT CO~ B~S D?J
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12-/22/ ZOO?
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.. ' . ... HO HARMLESS and DEMNIFICATlON AGREEMENT
In, compliance with the Rort Angeles MunICIpal Code, end In consideration ofthe IssuanCQ by the City of Port Ang"l"s ofB Slrael Use'
Pertilit lathe' undersigned allowing the placement of the above described street 'use or obstruction. the undersIgned for himself'and'
for his successors in interest, hereby agrees to indemnify, hold harmless, end defend the City of Port Angeles allalnst any clalma or
lawsuits fur personal inju/y' or property d'l1l1age arising out of, or In any way connected with. the placement of the use or obstrUl:tion
on !he City street. sidewalk. or planting strip. '
DATED thIS _ day of . 2001
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Applicant
SUBSCRIBED and sworn to before me this ~ day of
.2001
NOTARY PUBLIC in and for
Washington residing at
, (This pe""it, if approved, may ba terminated by /tis CilY of Poll Angeles wilhoulcauB& end at any lime)
(OFFICE USE ONLY]
the State of
Copies sent to:
Palicc _'
Fire ~
Planning _
F,lnance _
Oat.: _
Fee paid $ Receipt #
Agreement to Remove Encroachment signGd and
recorded on NJA
*************
Application reviewed and recommendation by City Engineer
or approve and wllh the
Date application received
Certificate of Insurance per PAMC 11.12.140(B)
on N/A
Date
following
is to deny
oonditions:
Application approved or denied by the Director,of Public Works
Date
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EMPLOYEES HAVING A NEED TO KNOW
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