HomeMy WebLinkAbout1404 Shirley Ct - Engineering
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PUBUC WORKS CONSTRUCTION
and RIGHT-OF-WAY pERMITS
City Phone: 206-457-0411, ext. 124
......t'UCANTfOWNERt \VV\ \4..ex""'\nr~' ADDRESS OF JOB:~ SH-l/2l.EiCDUleJ-
APPUCANT ADDRESS: PHONEi!h~{;..fdJb- LEGAL OF JOB: t-r It? 'U)esrVIe.uJ 1C,r
WORK IS [J OUTSIDE or [J INSIDE OF TRAVELED ROAD VALUE OF WORK IS:S (If work is oUlSide roadway
and is cquallO or I... than S2.000. lben permit may be issued to olber than licensed and bonded contractor.)
PUNS REQUIRED [J YES [J NO CONTRACroR: DATES FOR START
PERFORMANCE BOND REQUIRED [J YES [J NO AMOUNT: S
PROOF OF INSURANCE: [J WorIc $1.000 or leSs: S50,OOO peraooal injury. Sloo,OOO per incident. S20.ooo property
[J Work over S2,OOO: S2oo,OOO personal injury, S5oo.ooo per incident. Sloo,ooo property
[J Right of Way Use: S3oo,OOO persona1 injury. S3oo.ooo per incident, $100.000 property
Permi\leO IIIIlIenlmdI that DO aaeet may be closed lO traffic wtl_ approved by tho City Eugin- and Chief of Police in advaace of lbe
closure: that lbere ia a 24 hour minimum notice prior to inspection. and to call 48 hours before digging to: 1-800424-5555.
PERMIT
00411
& FINISH
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Sipd: ~:-"/}}7~ DATE:C ~ '1 h
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VT~ .,"",:. FEE .",." PAID TYPE FEE ..non PAID Ii
JJQKf OF WAY EXCAY. SOl'" ...... 'X () E.!2 I
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~ S12UlO SAPlIEWElIUFR' . AOO. UNIT SS...
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mEEI' cur . ........ DDJIl SEWB CAlfWATD MEI'D. ""...
lEWOVA!.
anD unrr 0' WAY weaK ..... ALTD.ATIONI "".00
aEPAfa TO lEWD
F1lI!Il\'DOA1<1' DEPOSfI' ~./ SToaM oaAOoI TA' 1113.00
lEI. 'fIATDIDVICE I- X SIt- ""... / '!Iff / ?,<:; aJ2 CATCH BASINS tN LOTS PEl EACH s.ooOD
us. 'fIATDIEKVIC1!: I- X )/4- ""... i
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co..... wATE1ID.VICE I' .II,(IID MILWAUKEE DIl. SEWEI ASSESS. mam /'EWM
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WATD IEJ.YICB. 0T1IEIl ESTlM..... IlIOKTOFWAY US! PDMITS vAJUES u. 1100
wATD SYS. DEV. C'HAI.GE -QQ?'~ TOTAU I I Ilf55l?JZ
TliiI..... ..... ... ___...-- .. ..--" ......... 1m __........ iD lad for.. ,..,........ iD .. ---. E..da,.........-....,.. MI .,. .raw iii We .~ --- .... .....--.
........ .............,..C\fJ'",... ~ .........CcdI. f'oIGUlinI..nIIiMd...........u M ___III-"*, u......._ 01_ appUc.... Ia. o/\hI Ci,~, Ccan", S~.. Of F....I~.
COMMENTS/CONDmONS:
C IDIlaIl [J Repair
CWaIermain
[J Saailary Sewer
o Storm Dnin
[J U~........d Teiepboue/Electrical
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JOOT TOTALS S .\ <=b s ')~ RECEIPT
~~
I_I <DlwsSUEDBY: oa
___ DATE:#.;
WORK ORDER No.
INSPECI10N FEES S
INSPIlC\'OR'S COPY . WlIl\'E APPLICANT'S copy. PINK OFFICE COPY _ CANARY pERMIT 0 0 4 11
PW.o109.03 (l2J931