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PUBLIC WORKS PERMIT INANIMATION — 206-433-0179 <br />Scope of Work (please provide detailed information): "' <br />Water District <br />❑...Tukwila ❑...Water District #125 <br />❑ ...Water Availability Provided <br />ewer District <br />❑ ...Tukwila <br />❑ ...Sewer Use Certificate <br />Submitted with Application (mark boxes which apply): <br />❑ ...Civil Plans (Maximum Paper Size -22" x 34 ") <br />❑ ...Technical Information Report (Storm Drainage) <br />❑ ...Bond ❑ .. Insurance ❑ .. Easement(s) <br />Proposed Activities (mark boxes that apply): <br />❑ <br />...Right-of-way Use - Nonprofit for less than 72 hours <br />❑ ...Right-of-way Use - No Disturbance <br />❑ ...Construction /Excavation /Fill - Right-of-way <br />Non Right-of-way <br />❑ ...Total Cut <br />❑ ...Total Fill <br />cubic yards <br />cubic yards <br />❑...Sanitary Side Sewer <br />❑ ...Cap or Remove Utilities <br />❑ ...Frontage Improvements <br />❑ ...Traffic Control <br />❑ ...Backflow Prevention - Fire Protection <br />Irrigation <br />Domestic Water <br />❑ ...Permanent Water Meter Size... <br />❑...Tempora Water Meter Size.. <br />❑ ...Water Only Meter Size <br />❑ ...Sewer Main Extension Public _ <br />o ...Water Main Extension Public <br />❑...ValVue <br />❑...Sewer Availability Provided <br />QMppIication\Fotme- Applicaiions On Linen -2006 • Permit Application.doc <br />Revised: 42006 <br />bb <br />Call before you Dig: 1- 800 - 424 -5555 <br />Please refer to Public Works Bulletin 01 for fees and estimate sheet. <br />❑ .. Abandon Septic Tank <br />❑ .. Curb Cut <br />❑ .. Pavement Cut <br />❑ .. Looped Fire Line <br />Private <br />Private <br />❑ .. Highline <br />❑ .. Renton ❑ .. Seattle <br />❑ .. Approved Septic Plans Provided <br />❑ .. Geotechnical Report <br />❑ .. Maintenance Agreement(s) <br />❑ .. Right-of-way Use - Profit for less than 72 hours <br />❑ .. Right-of-way Use — Potential Disturbance <br />❑ .. Work in Flood Zone <br />❑ .. Storm Drainage <br />❑ .. Renton <br />❑...Deduct Water Meter Size <br />❑...Traffic Impact Analysis <br />❑...Hold Harmless — (SAO) <br />❑...Hold Harmless — (ROW) <br />❑ .. Grease Interceptor <br />❑ .. Channelization <br />❑ .. Trench Excavation <br />❑ .. Utility Undergrounding <br />FINANCE INFORMATION <br />Fire Line Size at Property Line Number of Public Fire Hydrant(s) <br />❑...Water ❑...Sewer ❑...Sewage Treatment <br />Monthly Service Billing to: <br />Name: Day Telephone: <br />Mailing Address: <br />City State Zip <br />Water Meter Refund/Billinp: <br />Name: Day Telephone: <br />Mailing Address: <br />City State Zip <br />Page 3 of 6 <br />