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Job #:
Date: y
Jurisdiction: 1���-'. V
Right of Way Permit? ❑ YES ❑ NO
First Poss Start:
First Poss Comp:
11UGE1 SCIUND RXIIHICY
Address:: Sul 3 </i1 J
City/Zip:
c
Customer:
PM / Insp: INSP PHONE NUMBER
Est Duration: Email:
Job Description /
Scope of Work ,
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l ,,c ; f
New Construction:
/
ref �,`<e
❑ YES Q NO
(IFS,) PSE Dig
Plat Map:
I
/
1
P
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ly
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Work
Location
Size of Cut
Surface Type
Cc) of
CL
nF o sj Ulii c
ify,
tfw
& <7
/1/
of CL r,C
Sw 3�/h
b1R
3K
of
CL
&
of CL
of
CL
&
of CL
FLAGGERS
MPH
❑
TROLLY LINES
❑
BUS STOP u — "`
❑
METER HOODS # - ---,-'
❑ OFFICERS #_ — -
SPEED LIMIT
❑
TRAFFIC SIGNAL
❑
ARTERIAL
❑
NO PARKS # -----�
_---=
Rj Commercial
❑
Altered Commercial
❑
Leak Repair
Service
I n f o r m a t i o
n ❑
Template Bar --
❑ Residential
❑
Altered Residential
❑
CP Work
Pipe Size
Meter EFV ❑
Bollards 2.5" #
❑ Multi -Family
Ufl
Replacement Service
Pothole
❑
5/8" ❑
11/4" ❑ 250 ❑
1800
❑
Bollards 4" #
❑ New Constr.
❑
Main Maintenance
❑
Extension
❑
1/2" ]
2" ❑ 425 ❑
2600
❑ Stub
❑
Service Maintenance
❑
3/4"
❑ 630
10,000 ❑
Fuel Line Permit Needed
I
❑ Extension
❑
Valve Maintenance
❑
11/8"
�=ZO'06oo
44 Fuel Line Length:
❑ Compete Sery
®
Cut & Cap
Mtr LoC:
Fuel
Line Diameter: //! f �.
2(TTF S