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PRE -INSPECTION REPORT /Ui , 1500,M) E!dERt 1
Job #:
Date: Address:
it'e. int i
Jurisdiction:Cit l I
,fir, I(ir •. Y / Zip:
CUSTIFROWEWMRCR�
Right of Way Permit? ❑ YES ❑ No Customer:
INSP PHONE NUMBER
First Poss Start: PM / Insp:
First Poss Comp: Est Duration. ��, Email:'
Job DCOLA tion / come of Work
New Construction:
p .,
vr'
i •
j
�.
El YES P1 NO
It
If
00)
tA, jr
IFS / PSE big
Plat Map:j';
•,
tI_i ,
1,
1
i
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•
`'
I
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Work Location
Size of Cut
Surface Type
of
CL
UL 9W
(V
& Z4
W
of CL
Nocol cct
,
.)t
> of
CL
PC; S-+•\sct- R1-
& t1A W
of CL bnct
tar
cls Ave-
U'
of
CL
&
of CL
FLAGGERS # 01
MPH
❑
TROLLY LINES
❑
BUS STOP
#
❑
METER HOODS #
OFFICERS #
SPEED LIMIT
❑
TRAFFIC SIGNAL
❑
ARTERIAL
❑
NO PARKS #
Commercial
❑
Altered Commercial
❑
Leak Repair Service
Information
❑
Template Bar
❑
Residential
❑
Altered Residential
❑
CP Work Pipe Size
Meter
EFV ❑
Bollards 2.5" #
❑
Multi -Family
❑
Replacement ServicePothole
❑
El
5/8" ?r
11/4" E]250
E]1800
❑
Bollards 4" #
❑
New Constr.
❑
Main Maintenance
❑
Extension El1/2"
❑
2" ❑
425
❑
2600
❑
Stub
❑
Service Maintenance
❑
31401
❑
630
t]
10,000 ❑
Fuel Line Permit Needed
❑
Extension
❑
Valve Maintenance
❑
11/8"
'r-';
1000
Fuel
Line Length:
❑
Compete Sery
SU],
Cut & Cap
Mtr
Loc:
Fuel
Line Diameter: