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PUBLIC WORKS REQUEST <br /> FOR WATER DEPARTMENT COST ESTIMATE <br /> (ATTACH 1 WATER PLAN FOR REFERENCE) Date Request Sent: 9LZ=6 <br /> Associated Permit#: W1608-024 <br /> PROJECT ADDRESS: 215 W MUKILTE U (l <br /> DESCRIPTION OF WORK: INS ERVICE FROM HYDRANT TO BUILDING <br /> CONTACT INFORMATION: <br /> OWNER: NAME: OLYMPIC GENERAL CONTRACTORS <br /> NAME: OUR SAVIORS LUTHERAN CHU DALE <br /> ADDRESS: PO BOX 2927 ADDRESS: 2110 MADISON STREET <br /> EVERETT,WA, 98203 EVERETT,WA, 98203 <br /> PHONE: PHONE: 4253170851 <br /> EMAIL: EMAIL: <br /> APPLICANT: <br /> CONTRACTOR: CONTACT: ❑ Owner, ❑ Applicant, ❑Other <br /> NAME: [ConName] NAME: [ContactName] <br /> ADDRESS: [ConAdd] PHONE: [ContactPhone] <br /> [ConCi], [ConSt], [ConZip] EMAIL: [ContactEmail] <br /> PHONE: [ConPhn] <br /> EMAIL: [ConEmail] <br /> REQUEST FROM PUBLIC WORKS REVIEWER: <br /> COST ESTIMATE REQUESTED BY: <br /> COST ESTIMATE REQUESTED FOR: FILE <br /> CITY CREWS TO MAKE NEW CONNECTION TO MAIN <br /> ■ #OF CONNECTIONS NEEDED: <br /> ■ TYPE OF CONNECTION: <br /> ■ SIZE OF CONNECTION: <br /> • SIZE OF MAIN: <br /> ❑ CITY CREWS TO INSTALL PIPE FROM MAIN TO BACK SIDE OF METER <br /> • EXCAVATE,SHORE,AND RESTORE BY: ❑ CONTRACTOR, ❑ CITY CREWS <br /> • TRAFFIC CONTROL BY: ❑ CONTRACTOR, ❑ CITY CREWS <br /> • INSTALLATION AND PIPE THROUGH VAULT BY: ❑ CONTRACTOR, ❑ CITY CREWS <br /> OTHER DESCRIPTION OR REQUEST: <br /> C'42 el <br /> f o% 6//-f <br /> Z � 5 - ;7 <br /> Public Works Reviewer Signature Date <br /> REVISED 2124/2016 <br />