HomeMy WebLinkAbout1717 W 5th St - Engineering
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CITY OF PORT ANGELES
PUBLIC WORKS - BUILDING DIVISION
321 EAST STH STREET, PORT ANGELES, W A 98362
PUBILIC WORKS & R/W PERMIT
o Attached Notes
OWNER/APPLICANT
GEORGE TITTERNESS
1717 W 5TH
Port Angeles, WA 98363
000/600-0000
PROJECT INFO
Work is.
Plans Required
Contractor' OWNER
Performance Bond Required
Proof of Insurance
Work to Perform
Issued'
5/0212000
Permit No'
Work Order'
1055
o
PROPERTY LOCATION
1717 5TH ST W
Lot:
Subdivision:
Parcel No
Block.
~ Long Legal
Value Work.
$000
Start Date.
I I
Finish Date:
206/000-0000
I I
Amount:
$000
~ Install
o Repair
o Watermain
o Sanitary Sewer
o Storm Drain
o Underground Tele/Elec
~ Misc
SIDEWALK
PROJECT NOTES
INSTALL SIDEWALK NO FEE CHARGED SIDEWALK TO MATCH EXISTING ON BLOCK
IF NO SIDEWALK EXISTS ON BLOCK THEN INSTALL 6' WIDE SIDEWALK AT CURB
CALL FOR INSPECTION OF FORM WORK PRIOR TO CONCRETE POUR
FEES ASSESSMENT-
1 ) RIW Excav' $000 15 ) Other San Sewer' $000
2.) Sidewalk: $0.00 16) Sew Tap Wye/Man Tap. $000
3 ) Curb/Gutter' $000 17 ) Sew Capl W 1M Removal. $000
4 ) Driveway' $000 18 ) Alter Repair Sewer' $000
5 ) Dwy Culvert: $000 19 ) Storm Drain' $000
6 ) Street Cut: $0.00 20 ) Catch Basin per ea: $000
7 ) Other RIW $000 21 ) Sewer System Dev' $000
8 ) Fire Hydrant: $000 22.) Milwaukee Dr Sew Ass. $000
9) Res Water Servo $000 23.) R/W Use Perm $000
10) Comm Water Servo $000 24 ) Admin Cost (D.RA) $000
11 ) Other Water Service. $0.00 25 ) 0 RA. $000
12.)Water System Dev' $0.00 26 ) Misc: NO FEE $0.00
13 ) San Sewer SFR: $000 TOTAL FEE. $0.00
14 ) San Sewer MFR $0.00
add unit: 0 Amount Paid. $0.00
Receipt No
Inspection Fee $000 Balance Due. $0.00
R/W SANIT AR Y WATER DWY STORM DRA OTHER
Separate Permits are required for electrical worK, utilities, private and public improvements. This permit becomes null and void if worK or
construction authorized is not commenced within 180 days. if construction or worK is suspended or abandoned for a period of 180 days
after the worK as commenced, or if required inspections have not been requested within 180 days from the last inspection. I hereby certify
that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing
this type of worK will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any state or local law regulating construction or the performance of construction.
Signature of Contractor or Authorized Agent
f/~f)n,.)
Date Si nature of Owner (if owner is builder)
'---~ /.4/ ./ ~
Date
~.- -.---
.....
CITY OF PORT ANGELES
DEPARTMENT OF PUBLIC WORKS
. . . . . . INSPECTION REPORT. . . .
/
. . . . .
REQUEST
Date
Time
Received by
(phone, person)
Location of Work to be inspected
Name of person requesting inspection
Address of person requesting inspection
Type of Inspection (circle appropriate one)
/7/7
,
IA/I 5 ~
Phone No
Permit No /0 S5
,
Sewer Excav Other ~~ __
Sewer Foundation Framing
Chimney Plumbing Final
INSPECTION NOTES
Inspected Date 12:>// '7 bOt!)~ Time
Remarks e () ~ P/eT'iL
By /r=-
~
"-
~
~
~
r~
RESTORATION REQUIRED
YES
NO
SURFACE RESTORATION
SURFACE TYPE 0 Unimproved 0 Gravel 0 Asphalt 0 PCC
o Other
o Repaired by City
[] Repaired by Permittee
[] No Damage Found
Work Order #
o COMPLETE
o INCOMPLETE
(Continue on reverse side if necessary)
STREET SUPERINTENDENT
(DATE)