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HomeMy WebLinkAbout1307 Campbell Ave - Engineering ~,. ~ and RIGHT-OF-WAY PERMITS ~ City Phone: 206-457-Q411. ex!. 124 ......UCANT/OWNER.:~UJ EST" ~ ~ AD~RESS OF JOB:~ '3/)'7 . APPUCANT ADDRESS: PHONE LEGAL OF JOB: WORK IS [J OUTSIDE or [] INSIDE OF TRAVELED ROAD VALUE OF WORK IS:$ (If worle is outside roadway and is equal to or 1... than $2.000. thell permil may be issued 10 other than licensed and bonded contractor.) t'UJiLlC WUKlUl l..Ul'I:) J KUl.. .l.lVI' I. .&:.1.""''''&'& ~ 0i4-n-1 t2 be.J.l pLANS REQUIRED [] YES [] NO CONTRACTOR: DATES FOR START & FINISH PERFORMANCE BOND REQUIRED [] YES [J NO AMOUNT: $ PROOF OF INSURANCE: [] Worlc $2.000 or leis: S50.000 penonaJ injury. Sloo.OOO per incidelll. S20.ooo property [J Worle OVer $2.000: S200.000 persoaal injury. S5oo.ooo per incidelll. 5100,000 property [J Right of Way Use: 5300.000 personal injury. 5300.000 per incidelll. Sloo.ooo property Pemiitleo undentmdI that DO atnet may be clOIed 10 traffic ualea approved by the City Snain- and Chief of Police in advaIIce of the c101\U'C: thallhere i. a 24 hour ...;ft;"".m notice prior 10 inspection. and 10 call 48 hours before digging 10: 1-800-424-5555. .. . .,........~.......... II ........................ Qr.t......... .......,~..........,................... ---"-.......... ~ far........... _.........- .,.....,........... ........,..........t.., __............. __.... ___lid v....miI<< 'P'ftDIla......-.................. ~ -:-;Z;S;;;~-;h/n/?? /r,c DATE: 9//1//<9(.--, ...... / ' ,.. , . .--. ".: .""'" .~ I TTI'O FEE 'AID "'" FEE 'AJD ucurr Of WAY EltCAV. ..... -4// V- ~EWD.CSFaJ (6.1O'~6'.4' ...... _..w ~"'. IAN."-- IU"'. 'ft.- ...'" """"'"'" .",'" IAN lEWD tUn'. ADD. UNrr "'" _A' II25m IAN lEWD 011CEII . ...-1". =:SO.om__ Ma_lm tlW'I CULyuT ""'" JEWEl. TAP. IY crry frIO SIZSJXJ4JD01>> mEEr cur. ..... DII.IIlI lEWD CM/WATEI. NErD .,.,'" lDolOVAI. onID IJCJNT 0' W"ywoax ..... A1.1UATIOfrf' 130'" aEPAII. TO SEW'EI naa .......... STOll.. DUD\I T ", 1I1U:O lD. WATDIDV1CE I- X W ""'''' CATCH IAlD'lI IN LOTS PO EACH ....al us. W'ATElI'ElVlC!'- X "..- 1m'" SECOPfDAAY sEWEl ASSESS. IAlo,m in UU.OO__ I '''W'- 'YO' .....'" .~ $Y'. .~ ~"OF 1324.00 fEWM I COMM. WAT'D.ID.VICE ." - Il,a:o MO,.WAUKEE OIl. lEWD ASSW. suom/E'WN !."':-.!~ ""TO IDVIC!'. 0THEa """'An .1OIfT OF WAY USE PnMrTS VAJUES U .IICD WATO. In. DEV. CKAlGE mo'" IOWW TarA'-' I . TliI.aftII,.... .....-........ if...... 1M......... _ __............ ................ _ ~ Ed ~ . &.-d.-,-"'" .._ ti..,..~ ---.. '*- ~ ...................,..QIy.... ~.......c.s.. N......................, "'..........-- IM,....1ClN 01...,............ 01.,. C;I~. c_". Sa.. or F-'-'-l c--. COMMENTS/CONDmONS: ~ a [J~~ ~.. Repair 'Pu 51'7 IN?d'pr {?'T~~I""~ eN (?,/, Wt:?7e~ aSclitarySewer g'11/f7=--.;<;t:~ (/n;:--n:rt?;.a/Z/pmL e/ec../ g'//~I/c.. 54,.,. aSlDnDDniII ~vrnr 1...-0 ~/.._I/' . T 0- /- /' aUadwp......dTe1epbo1101E1ectrical ?'t?U/er //7 t?~?- e '11'- JUdlTTOTALS S RECEIPT # . ISSUED BYl_7::?~ PW~.03 11m] INSPI!Ct'OIt.s COPY . WlllI'E APPLICANT'S copy. PINK DATE:~ WORK ORDER No. 00454 omCE copy. CANARY PERWl' INSPScnON FEES S ~