Laserfiche WebLink
i <br /> 0923604-1 0007 08/24/2009 002 4 <br /> Engineering and Development Sql-y,jpfi$t Fee... 008193 skirt:,, 4G, <br /> G1I Y , -4 PO Box 547,Anacortes,WA 98221 „O A d` f <br /> TN:360.293.1920 FAX 360.293.1938 u n <br /> EMAIL: engineering@cityofanacortes.org ul Ilik, .e <br /> RIGHT-OF-WAY PERMIT APPLICATION <br />..-.� `SCOW 4•P.W•P m <br /> Appli nt shall submit application 5 days prior to start of work and application shall include: <br /> 1) Payment of assessed fee <br /> 1111 Drawing illustrating proposed work and its location. See checklist on <br /> Page 2 of 2. <br /> 3) Liability insurance CG 2026 or similar. City named as additional insured. Minimum$1,000,000 each <br /> ccurrence,$2,000,000 general aggregate and$2,000,000 products-completed operations aggregate limit. <br /> 4) Proof of both state and city business licenses <br /> 5) Performance Bond—Construction cost x 150% before work begins <br /> AVNw ❑ (6) Encroachment Agreement Required To be completed by City: ❑ Yes O <br /> Site Address: City Approved Exemption ❑ Yes ❑ No <br /> d 1(If I 0 1�, EDEN ASSIGNED PERMIT NUMBER: <br /> Parcel No. "Roo -- z c 009 2 <br /> 55 277 <br /> Owner Information (Required) Contractor Information (Required) <br /> Name c(1 motif (G" s C. GIW' g Name Ski°601 IYldONT/40 Sete 1<iGe_5' <br /> Address Address ml6 sc2 i _D <br /> City City <br /> Avltt.CO i'-'e t vtd�-` C0 C i•Derj ,G'v4- <br /> Phone "Xrq -3 — Q 2 0'd Phone lss 9, ! /ek <br /> Email _ ✓.__ Address SAjt f`/; v cc/e ict5e erg%2G/�°'`• <br /> Address �� <br /> Work Includes(check all that apply) <br /> ❑ Curb Cut ❑ Water ❑ Sewer g Storm X Street Cut ❑ Sidewalk ❑ Phone ❑ Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> CO1 PIE c-'t f-o61-ii•-) 64' 1o0F ®PA1/05 —re> TOR,IA 5 WE.&. <br /> REPL. C `(0EWAL< Ar 6 ikEVL CE atZ,W1:l.•.. At_t..t y <br /> APiQ12pAcCt-( u,I TI--( PAUEPtiEN <br /> \ ,,h , , <br /> v\- ., :vilwlit <br /> , :„.. ,.,, , Ito.%9 '041, <br /> 1 t_;ti. Approval Signature D.- e <br /> By sig ature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- <br /> ployees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, <br /> arisi ut of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf <br /> ou f is ance of is Pe/rmit,e for injuries and damages caused by the sole negligence of the City. <br /> scant Signature Date <br /> Final Inspection Approval Signature Date { <br /> 11 e_ W- aUC 'y — b�7C -' <br />