HomeMy WebLinkAbout1401 S N St - Engineering
..-~
ti ' PUBLIC WORKS CONSTRUCTION
and RIGHT-OF-WAY PERMITS
~ City Phone: 206-457-0411, ext. 124
J \\ I . \lUll
.vtUCANT/OWNER: \1'\'\ l-H"VY\~ Y"'I ADDRESS OF 1OB:--' qIJ \ 'So
;$qO- fi,q?- I J'
APPUCANT ADDRESS: PHONE !'5o/~ LEGAL OF lOB: L.f. WesTIII p,<I "HTS,
WORK IS [J OUTSIDE or [J INSIDE OF TRAVELED ROAD VALUE OF WORK IS:~(IN:ri is outside roadway
and is equal to or 1... than $2,000, then permil may be issued to other than licensed and bonded contractor.)
00405
PERMIT
PLANS REQUIRED [J YES [J NO CONTRAcrOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED [J YES [J NO AMOUNT: S
PROOF OF INSURANCE: [J WorIt $2,000 or leis: S50,OOO personal injury, $100,000 per incident. S20.000 property
[J Work over $2,000: $200.000 personal injury. $500.000 per incident, $100.000 propeny
[J Right of Way Use: $300.000 personal injury. $300.000 per incident. $100.000 property
PenniIlllO IIIIlIerstIIIId that no ._ may be clOlOd to tnffic uIIi_ .pproved by tho City Engineer and Cbief of Police in adVlllCO of the
closure: thsl there is a 24 hour "",,;nn,m notice prior to inspection. and 10 call 48 hours before digging to: 1-800-414-5555.
k ~_ .....fII~....... r. ........."....... ....arfll...A-'- _... fill. am.......,.................. ___ _eta ___ "-~ ................,
,0' ..--.---.---...--"....---........".........................----....-..-
.....&191. . _~-''''IbI.......
Sipcd: A. /I/~~ . DATE: <=5 "z, 4.t-.
//
If "m,; ...... .~ OF"." I
m< 'AID ,.,.. FEE 'AID
IXJHT OF WAY EXCAV. ...'" ~EWEIl (SFRI l6" 10 PI\.. ,.... 110'" 'X/) 9E I
V"'"
....",. IAN. SEWER tun'. lit... ....00
""""'"" 111S.(I) SAN lEWD tun . AOO. UNrr "'"
_AT SIZliJlJ .......... I ? h!?!2. IAN JEWEl. OTHEIS . Wio-17SJ:O; ~~i.so.cms_
~...I""
OWY ctlLymr ~, ....... lEWD TU. IV arT "0 II1SJID4JCIlUD
WY1!III ~
J1'UEI' cur . ....... ""'''' SEWD. CAlIWATB. METEI InS'"
8BKlv...
0T1ID.1XJHT 0' WAY WOIJC ....... ALT'ERATJONI 1lO'"
RDAra TO SE'NEI.
.... HYtlOAIlT DEI'OSlT STORM DRAIJ'l TAP 1115.00
us. WATDIOVIC'21- X SIll- ""'''' .......- ~/')O, CATCH IASUfS rN Lars n:l EACH ....00
m. WATDIEKY1CE I- X,,". "".00 i
.....w. .... .....'" 'I'Wnm."~.Clt..c. ...... //)4<90D I
COIoUl. WATDID.YICE ,-.",em MI1.WAUK.EE 01.. lEWD ASSESS. 1130.OJ1EWN
\.~:-J~
WATDID.VK."Il. 0T1II!J. DTlMAT1! lJOHrOFWAY USE PERMm VAAlESlS.IIOJ
WAT'D SYS. DEV. CHAlOE 5?'s<~ q]2 ~;:;..(fJ12 TOTAU I ,zz%~
!'bit......... ....__...... ...-......-...Im -*..... ill.. Jc:w.....,........ ill IbI ~ EadI.--.. ~...... 10 W .mII '" U. .~ ___ ill IIlII ~
....................f1I~Ckyf1l... ,....W.......CcdI. p.j~ PlmlIinII:l.......1ta1I bI......llO~ IbI ~_ 0I.,.~ III... 0I1ht Cil_. c.....". SIIII or F....I c-_.
COMMENTSICONDmONS:
a Inslall [J RAlpIir
a WIIennIin
[J Ssnituy s-
a Storm Drain
a U!.Al&..&,......d TeiephoDeJE1cctricsl
-
~TOTALS $ L.L- ~D
RECEIPT
d fn4- ISSUED BY:
DATE:..sb+ '7..(
WORK ORDER No.
lJlmT5'
OFFICE COPY. CANARY PERMIT
d-?f
INSPECI10N FEES S
PW.0209.03 (1V931
1N$"",,;,uK'S COPY. WlIlTE
APPUCANT'S COPY - PINK