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Engineering and Development Services 49 .q <br /> • G11.Yrr Off, PO Box 547 Anacortes WA 98221 �' <br /> o Q s <br /> TN 360.293 1920 FAX 360.293 1938 Z <br /> I. EMAIL engineering@cityofanacortes org <br /> y n RIGHT—OF—WAY PERMIT APPLICATION 6 0 <br /> �r �' RCW 19.122 Underground Utilities ,�. tQ <br /> `9CORD CALL BEFORE YOU DIG -;(800)424-5555 '4.P•vi.r- 1 dI I <br /> Applicant shall submit application 5 days prior to start of work and application shall include: �9( <br /> ) Payment of assessed fee <br /> l (2) Drawing illustrating proposed work and its location. See checklist on <br /> Page 2 of 2. <br /> t -1 1Liability insurance CG 2026 or similar. City named as additional insured. Minimum$1,000,000 each <br /> occurrence,$2,000,000 general aggregate and$2,000,000 products-completed operations aggregate limit. <br /> 4 -12frProof of both state and city business licenses <br /> Le— 5j"Performance Bond—Construction cost x 150%before work begins - <br /> U e y t - , o <br /> Site Address: City Approved Exemption r Yes [_ No <br /> \ 1 1 � '�"C` -(-c c_1-- EDENASSIGNED PER�'`NUMBER: ���I <br /> Parcel No. 4 6—7 ( • <br /> o f <br /> Owner Information (Required) Contractor Information (Required) <br /> Name , .3 zA.1,-1L v,__Q , Name svrctrldi-,-g41- f CetiJC. ✓--N_ <br /> Address Address -/ - <br /> City A _ l City / <br /> -.) 14/ C-( <br /> ---(---) <br /> / Phone Phone <br /> ' 60 1 --OYU `-/ 36 (-) /4I vI/O <br /> Email Email ' <br /> Address Intl 5. C.,„"-(A-/C,, , ( ;,,,,Address Sc-t.,vv "L._ <br /> Work Includes(check all that apply) ,. <br /> Curb Cut Water Sewer S'° torrn Street Cut C Sidewalk D Phone L Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> ems__d_ cb ri— ( tt t)vvv tfp( `Fi1 \ <br /> „CK)1.- <br /> C Approval Signal re �, Date <br /> -V-4 <br /> By signature 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 /> arising out of or in conn- tion with activities or operations performed by the Applicant or on the Applicant's behalf <br /> out of issuance of• rmit,except for injurie - • damages cause by the sole negligence of the City. <br /> � _ (fZq I( <br /> Applicant Signat 46 Date <br /> ill <br /> Final Inspection Approval Signatu' Date ; <br /> •: <br />