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^..-~. PUBUC WORKS CONSTRUCTION PERMIT () 0 4 59
r= and RIGHT-OF-WAY PERMITS
.~ City Phone: 206-457-0411, ex!. 124
......UCANT/OWNER:J) s'lA)eSr~iNYtl'Y1' ADDRESS OF JOB: tues- Sid e...
APPUCANT ADDRESS: PHONE LEGAL OF JOB: ;:;L r 03
WORK IS lJ OUTSIDE or a INSIDE OF TRAVELED ROAD VALUE OF WORK IS:5 (If worle is outside roadway
and is equal 10 or lcsa than 52.000. then permit may be issued to other than ligenscd and bonded contractor.)
PLANS REQUIRED a YES a NO CONTRACfOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED lJ YES lJ NO AMOUNT: 5
PROOF OF INSURANCE: a Worle 52,000 or lcSa: 550,000 personal injwy, 5100.000 per incident. 520.000 property
lJ Worle over $2,000: 5200,000 personal injuty, S5oo.000 per incidcot. S 100,000 property
lJ Right of Way Use: 5300.000 personal injury. 5300,000 per incident. Sloo.OOO property
Pemiitteo UIIlIentaDIU that DO _ may be cloecd to traffic unICS1 approved by tho City Engin_ and Chief of Polico in advmco of the
cl=; that there ia 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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\J ~ \AJe s-c C1oyy-~' . DATE: Z.1 \qc,
Sipd:
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TY?I! FEE 'All) TYPE FEE 'AID
IlJQIII' OF WAY EXCAY. ...... ~..!.EWE1 CSfI.) ,6' lit M.. 6"a4' "'...
..,.... 'AN. SEWD IU_'. ht.... -...
""""'"'" '1%5.(1) IAN SEWD. .....FJ.,. ADD. UNrr "...
lllIYEW A Y 112S.cG IAN IEWEl OTHEIS . 1.4.-17S. IOJlOSIIM
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OW\' CULVEIl' . ........ ..... ~M'.,.ycrrr..O 'Its,(04.J:>>.ClO
.mEET cur. ....... DlIlJlO SEWEll CAPIWATD. MEI'D. ""...
kEMOVAL
0T1IEI. JJaHT 0' WAY WORK ..... AL1"D.ATJONI 1lO'"
REPAIR TO SEWn
mI! IMllAHT DEl'OSlT STORM DUIN TAP 111.3.00
lES.WATnIBVaI. X SI1. ""'... CATCH BASINS IN LOTS PEl EACH ......
us. WAT'E1 ro:Y1C! I- X ]/..- ""... SECONDARY SEWD. ASSESS. SAIO.OO In UU.OO ClO.&IIlle i
InWA - .... --... SEWD in. -....; -....oe . 1)14.00 /EWM I
co....... WATD.IEJlVJCE I' -II_ MD..WAUKEE DR. SEWD ASSESS. IUO.o:J/EWloI
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WAT'D IBVIC2. OTHD ........'" RIOIfT OF WAY USE PElMfI'S VAAIESU.II00
WAT'EI. SYS. OEV. C'K.UOE ml.......... TOTALS S S
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COMMENTS/CONDmONS:
[J InII&II lJ. Repair
aWatermaiD
a Sanitary Sewer
a Storm Dnin
a Undcrgrouud Tc1ophone1Eloctrical
.JlMIT TOTALS $
RECEIPT
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ISSUED BY~
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DATE: IS lOtI I.i
lNSPEcnON FEES $
WORK ORDER No.
00459
INSP1lCI'OR'S COPY - WIlITE APPUCANT'S COPY - PINK OFFICE copy. CANARY pER!\fiT
PW~.03 (121931
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