HomeMy WebLinkAboutROW-2019-0001 - Engineering and Development Services ,`� •q
' 1. PD Box 547, Anacortes,WA 9E2211 �`� �F+
Tim 360293,1220 FAX 36Q293.1 P3B '
4 EMAIL: engineering@cityofanacortes.o g v
"�� rs7 - RIGHT-OF-WAY PERMIT APPLICATION
i=...�-� '- RCW 1 S.122 Underground Utilities '•
P
CALL BEFORE YOU DIG m (EDO 424-5555 Q P ,
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Applicant shall submit application 5 days prior to start of Work and application shall include: '
--_=�? ❑ (1) Payment of assessed fee •
0 (2) Drawing iIlustraiing proposed work.and its location. See checklist on
Page 2 of 2. •
0 -(3) Liability insurance CG 2026 or similar. City named as additional insured~ Minimum $t,0DQ,000 each
occurrence,$2,00Q,00O general aggregate and $2,000,000 products-completed operations aggregate limit
0 (4) Proof of both state and city business licenses
0.—( -Performance-Bond-==Construction cost X'150%-before work-begins
t ) Encroachment Agreement Required To be completed by City: 0 Yes i 'ND 1
. Site Address: City Approved Exemption 0 Yes 0 No
L� i�-t Q�GE C' If Dvt �� EDEN ASSIGNED-PERMIT NUMBER:
. Z0\ - 260 ` _ 4
Parcel No. p 5--tsi
$ d 7 -
Owner information (Reo> r#red) Contractor Irr formation (Required) .
Name Name
9� X� Ve C- ry /1/1/WJALAR.I. S Slime-
d, +tom
Address 3 Ct L 6 J AC/& Address -s 4�
city • City
Phone . Phone
15
_I�!-Ern ail
Address at a9 J V ( 1 , l 'r41, Address 5` i e) 0 i wt S'I-✓vc..4t)ve5 .Gbt,'"
Work Includes (check all that apply)
0 Curb Cut I] Water Yi Sewer ❑ Storm ❑ Street Cut 0 Sidewalk 0 -Phone ❑ Dther
IDescribe Work to be Performed: (Notification of Utility Companies is Required) -
7 ..
Tap ;eta cle_ 5-e Cle: 5/ mr of p r o p +✓t/'ly !hie. . -
•
',v '•'-1 i-'1 ;-1 -1-
• ri -1- I-.., 1 1 I it
•
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• C. ,4pp I Signature D a .
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signature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- :`;.. `s'1 .- ",
loyees and volunteers harmless from any and all claims, injuries, damages, lasses or suits including attorney — el- i-'' "= '
v ansing out of or in connection with activities or operations performed by the Applicant or on the Applicants behalf ..-1.. ,- ` :A
out.of issuance of this Permit,except for injuries and damages caused by the sole negligence of the City. 4:1 ;=! '=
I--1 !--
3plicant Sig hture Date , --'••.J 1
1`-1 I -I o
1 T:
Final inspection Approval Signature Date . ; ';' `.
• I....) t".,} a,
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NON- REFUNDABLE PERMIT FEE: (To Be Completed by City)
❑ curb Cut $50.00
0 Street Cut $50.00
❑ - inside Travel Way $50.00
❑ Outside Travel Way $20.00
•
0 Sewer inspection Fee $50.00
0 Sewer Re--Inspection Fee- $25.00
TOTAL FEE ASSESSMENT $
A Site Plan (to scale) must-be attached that include all of the following:
This checklist will aid the applicant in preparing a site plan. Permits that require installation of substantial improve-
ments may require plans drawn and designed by a licensed_engineer. Please check with City staff prior to submit-
ting your application.
• Draw the plan to a standard Engineering Scale [1'1 1 D', 1 a=2D° etc.lon a minimum size sheet of 8 'h x 11
and a maximum size of 11x17. •
• Include the owners name, the parcellD number, site address, north arrow, drawing scale and date.
• Include the contractor's name, address and phone number.
• Existing Right-of-Way lines, property lines, edge of pavement, curb/gutter, sidewalks, drivevirays and plant-
ing strips with dimensions between each.
Adjoining street name(s) to the reference property. •
• All existing public and private utilities in the area of the proposed project(Water. Sewer, Storm, Phone, TV,
Gas and Power), dimensioned to the edge of pavement, curb/gutter, sidewalk, driveways, planting strips.
}
• ® if applicable show easements, critical areas such as streams, wetlands and steep slopes.
® Proposed new construction. The proposed improvements shall be shown in heavier line type than the ex-
isting information
• Dimension the proposed new construction to the edge of pavement, curb/gutter, sidewalks, driveways,
planting strips, or another ideniiiiable site feature that will help identify the proposed improvements in the
field.
• Erosion Control Plan.
® Traffic Control Plan per current MUTCD-(See standard drawings at httn://mutcdffhwa.dot aov). If the work
requires any taneor street closures, the-City of Anacortes Public Workslnspector must be notified a mini-
mum of 48-hours prior to scheduled work for proper.public notification by the City of Anacaries.
Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right-of-way must be
bonded. The applicant and owner must use warning signs, traffic control, and barricades as necessary to ensure
public safety in the work area. The applicant and owner must restore the right-of-way to previous condition. Derma-
• nent restoration may include overlays of portions of the right-of-way and restoration of landscaping which have been
disrupted by excavation work. The applicant and owner are liable for damage to public and private property.
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Page 2 of 2
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