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E VE R E T T PUBLIC WORKS REQUEST <br />WASHINrTON FOR WATER CISP,ARTMENT.COST ES <br />WATER PLAN <br />826 PETERS PL <br />G&0020478 <br />CONTACT INFORMATION: <br />OWNER: <br />NAME: <br />Scott Smith, P.E. <br />ADDRESS: <br />15205 41st Ave SE <br />Bothell, WA, 98012 <br />PHONE: <br />4256592302 <br />EMAIL: <br />ssmith@slwsd.com <br />CONTRACTOR <br />NAME: NEED CONTRACTOR INFORMATION <br />ADDRESS: <br />PHONE: <br />EMAIL: <br />COST ESTIMATE REQUESTED BY: --FO •- lllk x <br />COST ESTIMATE REQUESTED FOR: <br />I CITY CREWS TO MAKE NEW CONNECTION TO MAIN <br />- 0 OF CONNECTIONS NEEDED: I <br />r n 001ifirl nest same 1212912020 <br />Associated Permit M PW2010-030 <br />APPLICANT <br />NAME: <br />Scott Smith, P.E. <br />ADDRESS: 15205 41st Ave SE <br />Bothell, WA, 98012 <br />PHONE: <br />4256592302 <br />EMAIL: <br />ssmith@sslwsd.com <br />CONTACT: <br />❑ Owner, IAwppllcanL 190ther <br />NAME: <br />Eric Delfel, P.E. 41 <br />PHONE: <br />2062840860 <br />EMAIL: <br />edelfel@gro.com <br />TYPE OF CONNECTION: Br IWVe Fost- 6_w Ac-R acaeu M1ere <br />w <br />SIZE OF CONNECTION: <br />SIZE OF MAIN: 1160 w <br />❑ CITY CREWS TO INSTALL PIPE FROM MAIN TO BACKSIDE OF METER <br />EXCAVATE, SHORE, AND RESTORE BY: <br />❑CONTRACTOR, <br />❑CITY CREWS <br />TRAFFIC CONTROL BY: <br />❑CONTRACTOR, <br />❑CITY CREWS <br />INSTALLATION AND PIPE THROUGH VAULT BY: <br />❑CONTRACTOR, <br />❑CITYCREWS <br />OTHER DESCRIPTION OR REQUEST:?- 5 A'ITi4C11i0 <br />�i/_�f z/i a/xuw <br />Public Works Reviewer Signe me Date <br />