HomeMy WebLinkAboutHwy101 & Delguzzi - Engineering
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.. '-'&1......_ T._"''''''-&~ __..'~....,______.
and RIGHT-OF-WAY PERMITS ~ I
City Phone: 206-457-0411, ext. 124 ^J~ ~ .
.vtUCANT/OWNER: Ll'~_::fl::~~ADDRESS OF JOB: 7~-U.N~/ l() \. ID ~ ~.
APPUCANT ADDRESS: PHONE LEGAL OF]O '
WORK IS 0 OUTSIDE or 0 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 0 YES D NO CONTRACfOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $
PROOF OF INSURANCE: 0 Work $2,000 or 1...: $50,000 personal injury, $100,000 per incident, $20.000 property
o Work over $2,000: $200.000 personal injury. $500,000 per incident, $ I 00,000 propeny
o Right of Way Use: $300,000 personal injury. $300,000 per incident, $100,000 propeny
Pemiillell IIIldentaDdI that DO .lRet may be closed to traffic unless approved by the City Engineer and Chief of Police in advlDce of the
closure: that there i. a 24 hour m;n;mnm notice prior to inspection, and to call 48 hours before digging to: 1-800-424-5555.
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Sipd: ,k.,A rrC- DATE: /~
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IJQHTOf WAY EXCAV. ...... /J/('.../ ...... I
~ SA.N'_~,EWU W'I.I 10' 10 PI\. 0'&4'
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........ I ....,.. FJ.'. III'" -.00
oWOI1I'Ttl< SI1S.co IAN IEWEJl ....~FJ.. . ADD. UNrr ".00
DllYEWAY SI2SJIO IAN ISWEI. OTHEIS . W.-I7.U:lO; 10'=1..
JoCa_sm im~cm.CiSCl.om a_
r:Jf/Y t'ULyot ...... ~I:'~'!.,.WNO SI2S.DOIlJCO.cD
snEEr cur. ____ ""'... lEWD. C>>/WATD MElD ,,,,.00
UMOV AL
0T1IEl u:nrr O' ViA Y WORK ...... ALTD.ATlONI IJO'"
aEPArJ. TO S'E\VD
FIlE HYD<AIlT DE!'OSfI' STOaM O~TA" 1113.00
aEI. 'fIATn 1ttVICE1- X ""- 'DUll CATCH BASIl'fI IN LOTS PEl EACH ...'"
lD. "'ATEl SDVICE I- X "..- 1m'" SECONO......V SE'ND ASSESS. IAIO.oo In 10613.00 cau_ l
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.... WArn ""'''''''' ,. Y ,. .......... SEWER SVS. ....rv.I"'UA,R.OE 132..00 fEWJo4 I
COWN. 'NATD.IDVICE ,..11_ MILWAUKEE Oil. SEWEll ASSESS. 1"0.00 /EWM
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"A1'8 SD.VJCE. Cl1'1ID. ESI1MA'" aIOHTOFWAYU'SE~m VAJUES".lloo
'NATO. SYS. DEY. CHAaOE m:>.oo IEWW TOTAL< I I
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goEfr~~Y~mo'N;-~%.. '<Mo. ~~~:;A...~1/;~-;::;v:....~~T;.;:~-q~/
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[J Saailaly Sewer P / v6 -l ~~ .
[J Storm Drain
[J UndergrouDd TeIephoocIElectrical
JWITTOTALS $
RECEIPT
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ISSUED BY:
DATE~
INSPEcnON FEES $
WORK ORDER No,
00441
INSPECTOR'S COPY. WIIlI'E APPUCANT'S COPY. PINK OFFICE COPY. CANARY PElUtIIT '
PWm09.03 (121931
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