HomeMy WebLinkAbout616 S I St - Engineering
e PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
~ City Phone: 206-457-0411, ext. 124
....r'UCANT/OWNER:~ht4/ #tU6...,:/ ADDRESS OF JOB: ;I; / (/;
APPUCANT ADDRESS: PHONE LEGAL OF JOB:
WORK IS 0 OUTSIDE or 0 INSIDE OF TRA VELED ROAD VALUE OF WORK IS:S (If work is outside roadway
and is equal 10 or less than $2,000, then permit may be issued to other than "censed and bonded contractor.)
PERMIT ~2
~o
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PUNS REQUIRED 0 YES 0 NO CONTRAcrOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $
PROOF OF INSURANCE: 0 Work $2,000 or leis: $50,000 personal injury, $100,000 per incident, S20,OOO property
o Work over $2,000: $200,000 personal inJury, $500,000 per incident, $100,000 property
o Right of Way Use: $300,000 personal injury, $300,000 per incident, $100,000 property
Permittee undcntmds that no street may be closed to traffic unless approved hy 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 call 48 hours before digging to: 1-800-424-5555.
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b.,1illddId. _ordampm~.propwI)', ~OI'~" ~ prcaJaallllWUll oILll)' WCII1lInkI\.l.b:alrdar~ kTmloltblt.ppl;c.tkaUld th= pc:rmil or pc:rmi~....nid:llDt)' b& &J"UIICd ilI_pa-.c
S~ ~:z::~- DATE: *~/ff
. " I I I I I!
lYPE FtE "0'0 'AID TYl'E FEE REQ'O 'AID
lIOKf OF WAY EXCAV. ..,'" L---- 4/J €f2.- ~IEWEJl.(SF")(6'IOPI1..6'.4' "'.00
"".00 SAN. SEWER 'U~ . 1.11W1 ~.OO
'"""""" 112:1.00 SAN SEWER. n.fFlll . ADO. UNIT ".00
DOIVEWA Y SIU.oo SAN SE\lr'D 0'TlID.S . MiD-m.OO; SO.tW11JI
Ma-$7.~ 100 oco.l'i1O.0025 u.~
OWYC\Jl.VDT -~. ..,'" SEWD TAP. BY CITY 1'l0 SllH~1)Q).OO
wYEJM^",HOLE TAP
S'T'UEI'cur.~ ID).OO SEWD. CAPIWATER METEJl. SW.OO
IlEMOV Ai.
OT1lEIlJOKT OF WAY WORK 1<0.00 ALTEJlATlONI SJO.OO
kEPArJ. TO sE'ND
,
mE IlYDIVJ<f DEPOSIT STORM DRAIN T "p IlU.OO I
W. WAT'E1 S!!J.V1CE I" X 511" 15"HIO CATCH BA.S~S IN LOTS PER EACH 1<0.00
m. WA.T'D. JDVICE 10 X )I". 15".00 ~'O.OO In S6IHO cuux ,
SECOI'lDAJlY SEWEA ASSESS.
"" WArn """,... ,. X" '-.00 S~Il.SYS.OEV,CHAJlGE tJlol.00/E'NM
COMN. WATD. SDYlCE 10 - 11,0::0 Mn.WAUKEE DR. SE\IIEk ASSESS. SUO.OO /'EWM
!~:-.!~
WAlU.IDYICE. OTHD. EmMAT1! RIOIfT OF WAY USE PEllMrTS VAlUES ". lIto
WAT'D. SYS. OEV. CHAJ.OE 17.50.00 /EWM TOT AU . . LZ/J-"'~
rw.-ut...... __ __ epptioaaI it JRmMl u. ~r..I060 tl& _k obcri'-d ill oM for U. ~ ~ ill lbI """tication. Ud:l pumn ill ~ ~ \0 \tc IoCnno of \tc .,_ ~ ill 1bl-.ppb"'"011
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COMMENTS/CONDITIONS:
o Install 0 Repair
DWatcnnain
o Sanitary Seww
o Storm Drain
o Uodetground Te1ephonelEloctrical
..:KMIT TOTALS $ -/;J c/O - RECEIPT
K!i{) - duHr A-t (!4XO-biZU-6
# /1/1 ISSUED A~~:;;Z~~
om ~~
WORK ORDER No,
INSPEcnON FEES $
PW-0209.03 (12193)
INSPECTOR'S COPY - WHITE APPLICANT'S COPY. PINK OFFICE COPY - CANARY pERJ\1IT