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,„ <br /> Engineering and Development Services ..*.P -40 get., PO Box 547,Anacortes,WA 98221 ITN:360.293.1920 FAX 360.293.1938 t ZEMAIL: engineering@cityofanacortes.org <br /> RIGHT-OF-WAY PERMIT APPLICATION a <br /> ' RCW 19.122 Underground Utilities <br /> C O CALL BEFORE YOU DIG -(800)424-5555 '4•p`• •p' <br /> Applicant shall submit application 5 days prior to start of work and application shall include: <br /> • (1) Payment of assessed fee <br /> ❑ (2) 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 /> occurrence,$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 /> ❑ (6) Encroachment Agreement Required To be completed by City: ❑ Yes ❑ No <br /> Site Address:kti <br /> Al City Approved Exemption ❑ Yes ❑ No <br /> IDEENN�ASSIGNED PERMIT NUMBER:: (� (�Parcel No. �,P 003 - a0 ( I - 0 V `�1 <br /> Owner Information (Required) Contractor Information (Required) <br /> Name -- a f /e, O Name <br /> Address lootiv Q..(,_ Address 2 )-g d <br /> City City <br /> Phone c'.?".— /'vb c(7 Phone 3c -7 7 /. 9c° <br /> Email ,e `C Email {C'(liL <br /> Address Address CQ/76Ccv hd/4 /CO/y <br /> Work Includes (check all that apply) <br /> LI Curb Cut ❑ Water ;Sewer ❑ Storm ❑ Street Cut ❑ Sidewalk ❑ Phone Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> 'fit St our 4t. t~i-t, 416/ <br /> -o r,- <br /> - C) <br /> ^t C6 <br /> vid . ' r -1 IA <br /> a: t,.,) <br /> 1,ft CI <br /> 'Cr. ppr al i ature G Date 0 CID <br /> 0 CO <br /> P•:: G <br /> By signature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- co t-- <br /> ployees and volunteers harmless from any and all claims, injuries, damages,losses or suits including attorney fees, 1.-. <br /> arising arising out of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf qt n co <br /> out of iss nce of this� rmit,exceptfor injuries and damages <br /> )31L--- <br /> caused by the sole negligence of the City. t.r <br /> '«:` <br /> / o�p� C I.-. <br /> App is t Signa re Date o <br /> u <br /> r- <br /> l <br /> Final Inspection Approval Signature Date { t`� <br />