HomeMy WebLinkAbout1833 W 12th St - Engineering
PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
City Phone: 206-457-0411, ext. 124
1 Si'"3~ l0 lZ~.y., .
I? fc>\ t::'-~ I
PERMIT ~ 0 4 3 2
~
~
.v....UCANT/OWNER:LL! I tp ~ C~A-h
APPUCANT ADDRESS:
ADDRESS OF JOB:
PHONE LEGAL OF JOB:
WORK IS D OUTSIDE or D INSIDE OF TRAVELED ROAD VALUE OF WORK IS: $ (I f work IS outside road'^,'
and is equal to or less than $2.000, then penrut may be ISsued to other than ilcensed and honded contractor i
PLANS REQUIRED D YES D NO CONTRACTOR:
PERFORMANCE BOND REQUIRED D YES D NO AMOUNT: $
PROOF OF INSURANCE: D Work S2,OOO or lesS: S50,OOO personal injury, $100,000 per incident, $20,000 property
D Work over $2,000: $200,000 perso\l1l1 inJUry, $500,000 per InCident, $100,000 propen)
D Right of Way Use: $300,000 personal LDj ury , $300,000 per LDcldent, $100,000 property
Permilteo undorstmcla lbat no street may be closed to traffic unless approved by tho City Engineer and Chiof of Polico in advance of tho
closure: that thoro is a 24 hour min.imum notice prior to lDSpCCtion, and to call 48 hours before dtggLDg to: 1-800-424-5555.
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Sipocl:',; ~.(!!" DATE: I,J (eil ci~-
/ I (/ ~
DATES FOR START
& FINISH
"""
FEE
REO'O
'AID
rm
FEE
! REQ l) I I'AJlJ
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JJGKf OF WAY EXCAV.
"".00
/ {j ()/
SAN. SEWEJl. (SFR) to" to PiL. 0.... ~.OO
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"".00
il8IllU1TEl<
SI23.00
SAN. SEWER (Mflt). 1"lZUl
SA.."I SEWER (MFR) . ADD. UNIT
,",00
SHP
DlNEWA Y
Sl2.:I.00
SAN SE'HEll. OTHERS. MiD..573.00,
Iota-USO
SO.COSI'l
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DWY CUL~ , ......
"".00
SE\VEJt. TAP. BY CrN NO
'WYEIMANHOLE TAP
51:2J.00I$J(X).00
ST'lEET CtIT. ~
5200.00
SE\VEJt. CAPM'ATEJt. METER.
REMOVAL
122.:1.00
OTHEIlJGHTO' WAYWORX
"".00
AlTERATION!
REPAJ'R TO SEWEll.
5)0.00
FlRI! ItYDAA)(T
DEPOSIT
STORM DRAIH TAP
SllS.OO
W. WATIll SD.ViCE I" X,,,'
"'Xl,oo
~
"'7C,O -
CATCH BASll'lS IN LOTS PER EACH
S4Q,OO
W. WATEJ.!Elf.V1CE I" X 3'" "'73.00
SECONDAR Y SEWER ASSESS
-S,41G,OO ~.lQrrroou.:,6:
J.E!.WATI"'EIlVJcr,'x I'
""'.00
S~RSYS DEVCHARGE
M
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COMIo4. W...TD.JD.ViCE
1".SI,~
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Mu'WAUKEE DR. SE'n'ER ASSESS
SIj()oot'EWM
WATEJ,IEJ.VJC'I" OTHER
I!>TlM A Tl!
RIOHT OF WAY USE PERMITS
VARIES", SIOO
'NATa In. DEY. CH.UOE
Sl:;a.OO'L~"'"
<:<x3
TOT AU
TWo~ lil&ilbl___-.d &ppticanl ~ ~ lb,:, pcmu~ Lo d<llill: "'<lrk Qoocnbl:l<j III ond rOflb,:, ~.~ '" ~ "W1,""lKll\ uch Pc""" .. Innu><l 'u/:>J"<'lIO <he "".... oil!">: 'L~ 0Ul1l4~ '" lir 'PI'''.~
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COMMENTS/CONDITIONS: l -> / - ) e ,', 'I i""...
CJ Ioatall D Repair 'ORA-. 03.-01 442 "--P + in--fo"-"y~+ Oi:;;...u.
[J Waterm&in =1
D Sanitary Sewer (Df.pz..ICXo14/~'l) pe ,.-d~ + !+..Dm IN .05 _(l\
o Storm DniII ?fav1- cha ct,e.... "3/z0/Q.q
DUnctcrgroundTelephonelEloctricaJ -_"':lce {'CC ~)T if /),<. ic.~.C-l. '1 ()'... (
H I~? &. ISSUED BY: . ~(,r.
.;KMIT TOTALS $ ( \ '1 c::;
RECEIPT
DATE:L(I '11'1
,
INSPECI10N FEEs $
WORK ORDER No.
00432
PW.0209.03 (12193]
INSPECTOR'S COpy - WHITE APPLICANTS COpy. PINK OFFlCE COPY. CANARY PElUv1IT