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APPLICATION F PERMIT TO PERFORM WORK ON PUBLIC RIGHT-OF-WAY •
NSTRUCTION ENGINEERING DIVISION N2 13350
PERMIT NO: Vv
("7 )I]�TE PROJECT NAME: .0`..-69fJL. -it t// �}, DATE ISSUED: /2^ 6---
"E"•",?fT' PROJECT ADDRESS &�f) 1' r _ ) .4 1, a2i1. . DATE EXPIRES: 4"S '•0/1
QUARTER SECTION ] '� DATE ACCEPTED:
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Appicants Name App%cant's Sig
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11 Amass
WATERLINES LF Dia. LF _ is SANITARY SEWER _LF ,�Dia LF _Dia. MISC EA Manholes
_LF Dia _LF _Dia. LF Dre z LF _Die • _ EA Fire Hydrants
IV ❑ Cash Bond Af00unt NaRWACN¢ess M person to return Uond ta:
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1,lr . Surety Number
Issued by. / J / s1.y _•J/" "Wmmenls t,,t�; ,
UTILITY PERMIT FEE / U'�PERMITS 7. QUANTITY i UNIT PRIDE,.. BASE FEE $ 50.00
TRENCH(RAN) PAVEDlF y@.$0.15 rLF $
TRENCH(RIW)UNPAVED $
PITS EA $I0.00/EA $
STREETLIGHTS EA @ $50.00/POLE $
TOTAL: $
STREET PERMIT FEE STREET IMPROVEMENT PERMITS QUANTITY UNIT PRICE BASE FEE S 50.00
PAVING - SY @$030/SY $
tWIHOLES EA ,. $40,o3ttA $ 1
CURB&GUTTER ,LF •g-$0.201LF $
VALLEY GUTTER sr ': @$008/SF $
SIDEWALK - - ' -- SF @ $0.05/SF. .5._-- _ _- _.
SIDEWALK RAMPS SF @ $0.10/SF $
PRIVATE RESIDENTIAL DRIVEWAY EA @ $25.00/EA $
DRIVEWAY SF @ $0.10/SF $
-
CURB CUT EA @ $200.00/EA $
CATCH BASIN EA @ $40.00/EA $
TOTAL:_$
WIS PERMIT FEE WATER/SEWER I STORM DRAIN PERMITS QUANTITY UNIT PRICE BASE PEE $ 5000 Z
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WATER LINE LF @ $0.90 tLF $ ( D
SEWER LINE IF @$0.60 LF $ —a
W
STORM DRAIN LF @ $1.00 AF $ L,0
- al
IRRIGATION IF @ $1.00/LF $ o
MANHOLES EA @ $40.00/EA $ J�
WET TAPS / EA @ $303.00/EA $ �/e /�-},�
TOTAL: $7,5/•7 Ala
T 4.1..50;•-7"
TOTAL PERMIT FEE S