HomeMy WebLinkAbout716 S I St - Engineering
~."-~ PUBUC WORKS CONSTRUCTION PERMIT . 00456
and RIGHT-OF-WAY PERMITS
~ City Phone: 206-457-0411, ext. 124
.~ . " fJ
....tUCKNT/OWNER.: IJStlHI3TC1n;.-.",......, . ADDRESS OF JOB: '/1 (Ii' S,.); .s;r'
APPUCANT ADDRESS: PHONE LEGAL OF JOB: B Jr - z- 7
WORK IS lJ OUTSIDE or Cl INSIDE OF TRAVELED ROAD VALUE OF WORK IS:S (If work is outside roadway
and is equal to or less than $2,000, lben permit may be issued to olber than licensed and bonded contractor.)
PLANS REQUIRED lJ YES Cl NO CONTRAcrOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED Cl YES lJ NO AMOUNT: 5
PROOF OF INSURANCE: Cl Worlt $2,000 or leis: $50,000 penonal injury, $100,000 per incident. $20.000 property
C Work over $2,000: $200,000 personal injury, $500,000 per incident, $100,000 propeny
C Right otWay Use: 5300,000 penon.aI injury, $300,000 per incident, $100,000 propeny
Perniittee undentIndI thal DO _ may be cloeed to traffic unIea approved by the City Ensin- and Chief of Police in advance of lbe
c101\U'C; that there is a 24 hour m;n;.....m notice prior to inspection, and to call 48 hours before digging to: 1-800-424-SSSS.
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DATE:
7{2-C1,/Qe-,
,
Siped:
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'mI! FEE Tm! FEE
IJOKt' Of WAY EXC4V. ...... ///I( /' ~.!.~ISfRI(6'w>>PJl..6."4' ......
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mEEI' cur. ........ DlllJlO lEWD. CA,lIWATE1 NErD sm...
OEMOVAl.
onma lJCJHror WAY WOIK ...... ALTDATIONI SlQ..,
aEPAIR TO lEWD
".. KYtlOAIlT "EPOSlT STOaN DRAIN T A' 1115.00
lES.WAT'D.1l!aVk.."E1.XW. ........ CATCH BASINS IN LOTSPEJ: EACH 141.'"
lEI. WATD.IDVICE I- X 31.- 1m'" SECOHOAAY SEWD. ASSESS. s.al0.oo In UIS.OO .,....
... WA"""""""v' -- ..wn ~. "~ ~"GE t.)14.00 fEWM
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WAT'D IDVJCI. 0T1ID. EmMA'" atOK!' OF WAY USE PEaMm VAJJES Sj . SIOO
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COMMENTS/CONDmONS: /I (011'1......;. <:::." d' 'fY:. ~ G // ftc- f,Ud..{-e.r IJ. g,/<i~
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OU_T~ '''<L\~
JWIT TOTALS $ RECEIPT # ISSUED BY: 1 OtJ/Jf.iVt01 DATE:
INSPECTION FEES $ WORK ORDER No.
OFFICE COPY. CANARY PERMIT 0 0 4 5 6
PW~.03 (111931
INSPI!CTOR'S COFY . WHITE Al'PUCANrS COPY. PINK
~
JL. -19' 961FRI) 08:45
US WEST
J- A j:{f
TEL:360 452 8660
/ -.' .5 t,L)" 'f:/!5 - 'i'/'>.r
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P.OOI
b ~3~S LJ
BURIED SERVICE WIRE #:
WORK ORDER DATE: M/11/9'
WORK lOCATlON Wire Cenler W26
Addr.u .--21.' r J;T.
~;:~Oh'~~~t'h,:ltJJtIf SlJIu, ~
Subdivision
Cust. Signature 10ptionall
Customer may refer questions to: 800-737.0477
SUbmitredby:~""/7 OCB _Pager """0 -1J9~-'
INSTALLATlONIREPAlR
New 0 Cf 0 SON
Rearrange 0 Add Une a
Repair Pf 005 CJ TN#
1TN#
CBRIT
Y a N
45"J - ..,- 0 " 6'
Found Temp
Temporized?
o
({
PRE.PROVISIONING
Pre Bury a
Conduit Placed Partlal a Complete a
BSW In Open Tr. Partlal a Complete a
Extend SSW on panial conduit 0( open trenCh a
Home Ready for SNVGNO D Not Ready D
l Y L -.L ...lL T -1- (11
( Ildd$ to right if sketch senl to contraCtor)
Is there additional customer billing?
Does Tech need notified?
MAP II
DYes tJ No
~ Yes a No
CSL PAIR COLORIBP TERM ADDRESS
/ J/PS iJL/U BI.W 7~4 r J/.
,
CONTRACTOR'S ACCEPTANCE
Firm
Signature
Title
USWest group doing work
Bill to: USWest CommunicatIons
Attention:
Address:
'CitY':
Date:
Zip:
!Recommended: Data:
Approved by: Date:
em
PERMIT REQUIRED? AI YeS a No
Received frOm Verbal 0
Jurisdiction No. Date:
c-
,j
\J"
\P
c
COMPLETED BY:
Call
Date:
for service connection
(T~ 'ftl J.$"O' /1 f, IU tr-
~ d .A4 feti- LL.$j-
Sketch Worlc Requ/1'ed . Include nearest cross 5tnlet Indicato North
and wire length 1 ~
u.. form RG ~I.oO'7.11C1Ald;u-l SPO=" ~
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