HomeMy WebLinkAbout726 E 4th St - Engineering
e PUBUC WORKS CONSTRUCTION
_ and RIGHT-OF-WAY PERMITS
~ City Phone: 206-457-0411, ext. 124
..dUCANT/OWNER:h~~~ ~tV2;f ADDRESS OF JOB: 72~
APPUCANT ADDRESS: PrJ. t::hx JhZZ-. PHONE 'i-lobCf. LEGAL OF JOB:
WORK IS 0 OlITSIDE or 0 INSIDE OF TRAVELED ROAD' VALUE OF WORK IS:$ (If work is outside roadway
and is equal to or less than $2,000, then permit may be issued to other than licensed and bonded contractor.)
PERl\fiT
00424
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PLANS REQUIRED 0 YES 0 NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED 0 YES 0 NO AMOUNT: $
PROOF OF INSURANCE: 0 Work $2,000 or leis: $SO,OOO personal injury, $100,000 per incident, $20.000 property
o Work over $2,000: $200,000 personal injury, $SOO,OOO per incident. $100,000 propeny
o Right of Way Use: $300,000 personal injury, $300,000 per incident, $100,000 propeny
Petmiuee undentanda that no atreet may be closed to traffic unless approved by tho City Engineer and Chief of Police in advance of the
closure: that there is a 24 hour minimum notice prior to inspection, and to call 48 hours before digging to: 1-8oo-424-S555.
III .. ~_.,...ffIIlHI........Iit""'...."'a.~"''''ClJfII~~....tJIl11~CII'...,..IbIJl.--~to_~&cIII...IWIiBIy.~
for.,.......... ordm.p 11I,-- .~. ~or ~. It. ~ -'* oila)' --" wDau__1Is I&mII g( \biI11lPI;.;.Ucm &ad \i& permit or pcmull....tlidl ~ 1:1I"'" iD_parw
~ _tbIldlfllMid LIabUilaI_.....___~a~.
Signed:'" ~ :s-' /~/ J 5-/- '76'
- DATE:
r,- '-
.:" ......... . '''''D REO'D I
TYPE FEE PAm TYPE FEE PAID
lJOHT OF WA.Y EXCAV. ..,.00 ~fWER (SFill l6" WI M.. 6'.4' "".OJ
~.crl" SAN. SEWD IU'flp. 101'" "".OJ
""""'""" $123.00 SAN sFHD. IUFR'. ADO. l.,'!'HT U,OJ .
DIJYEW A Y SI15m SAN SEWEll 0THEJlJ . Mia-nJ,co. 5O~hl
Ma_n,., Ima:o.rM.OJ'Uua:u
F1f('( CULVDT ~ SEWD. TAP. BY CITY p./O SI23J1)1lJOO.OO
0.- ......... WYElMANHOLE T A1
STJ.EEI' CUT. a...c..ica ,m", SEWD CAPfWATER METER. sns.OO
REMOVAl.
omEI. JJOKT OF WAY WORK ..,'" Al.TEllATJONI no.oo
REPAIll TO SEWn
FW! IlYD<AI'T DEPI>Srr STORM DRA[1<o/ TAP sm.oo II
m. WATER SEJlV1CE I" X ,.... SSM.OJ CATCH BASll'IS TN LOTI P'EIl EACH SoC:lOO 11
RES. WATD. SEJ.VlCE I. X )/~" s.:rn.OJ tb& tIP SECONDARY SEWER ASSESS. ""0.00 in $.61'.00 oo.a.a... I:
J.ES. WAT'D. SElI.V1C'E." X I. ~.OJ SE'W'ER. SYS. OEV. CHARGE UROOtE'NIo4 Ii
COMM. WAm SElI.V1CE I". u,a:o MILWAUKEE DR. SEWEl,usESS. 1130.00 IEWM
~~:-.~~ ..
w A TEJ~ SEll VJCE . 0T1IEk EmMA,", RIGHT OF WAY USE PER..1,UTS YARrES U. 1100
WATER SYS. DEV. CKAAOE S750.OJfE'\lr'lof TOT AU , ,~~~. II
ThiI--'- .....11.-................-.. ~u. ,-_IOOOIM-*i o-c:rit.d a. forlbl ~~ a u. ~ E.aclIIp'-tmU io....- .....,...IOU'IO...... oIw 1'_ __albl: ~......
_..a;..IOIbI~oIlb1CityolPOl'l""",W~Ccdo:. f'/atNnt pcnai'llildbl_u..LIm:dMaliId IO_~..,............... 01....... .pptat>.. U1'* olw Ci,.. C"'-Y. S~.. Of F...... c.:-_.
COMMENTS/CONDITIONS:
O!nslall 0 Repair
OWalermain
o Sanitary Sower
o Storm Drain
o Underground To1ephonclEIectrical
/, /I. t9.J
~KMIT TOTALS $ (fZ(Y,
RECEIPT
#~ ISSUED BY:
--;K:P
DATE: '3-I-'tt,
PW.0209.03 !l2l931
INSPECTOR'S COPY - WHTl'E
APPUCANl"S COPY - PINK
WORK ORDER No.
OFFICE COPY. CANARY PERl\llT 00424
INSPEcnON FEES $