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1 la . : .tie_- 113 S <br /> Engineering and Development Services 1-49 <br /> ` qG1Y �� PO Box 547,Anacortes,WA 98221 �''© ��TN:360.293.1920 FAX 360.293.1938 <br /> EMAIL: engineering@cityofanacortes.orgRIGHT-OF-WAY PERMIT APPLICATION � !� <br /> RCW 19.122 Underground Utilities �../ <br /> )47- CALL BEFORE YOU DIG -(800)424-5555 '4•p•W•P'hall submit application 5 days prior to start of work and application shall include: <br /> ) Payment of assessed fee <br /> 0 (2) Drawing illustrating proposed work and its location. See checklist on <br /> Page 2 of 2. <br /> V(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 an(city business license)— /i '('R,....e.ss <br /> (5) Performance Bond—Construction cost x 150%before work begins <br /> W.4) Encroachment Agreement Required To be completed by City: 0 Yes ET--No _ <br /> Site Address: City Approved Exemption ❑ Yes ❑ No <br /> I( (0 I I!N SW-ea— EDEN ASSIGNEDASSIGNED PERMIT NUMBER: <br /> Parcel No. Z 'IT` - 00(� <br /> �" <br /> � 594� <br /> Owner Information (Required) Contractor Information (Required) <br /> Name \ 1 Name <br /> JZ t►,,OQ.IUS INsp1120) 17k55.1(..tJ hoc-+512. 4.11z2.IJ <br /> Address Address <br /> V lv 3S1' Fk--1"C-c I idc'ba1 lrAk ISTLE 46 1 <br /> city .e -Te6 , �p 322I city <br /> A paap,c.oe °,, tJb 41‘6221 <br /> Phone 2�3 - tm°1 I O Phone 3(00.(O i0- 1.02-0 <br /> Email Email <br /> Address Address <br /> Work Includes(check all that apply) <br /> ❑ Curb Cut ❑ Water Sewer ❑ Storm ❑ Street Cut ❑ Sidewalk ❑ Phone ❑ Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> --- 4 Nl-scLT tot—. or- Fa‘ am. ` .'Tt., A.rNlac c'1m.5 ' =� S1/417-k. <br /> NU S I?e_ Ft a`! 1 . GA1-t, I t-5 'te.-1-‘At--1 , <br /> of -Si-Iv <br /> City Approval Signature Date <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 connection with activities or operations performed by the Applicant or on the Applicant's behalf <br /> out of issuance of this Permit,except for injuries and damages caused by the sole negligence of the City. <br /> A li n Signature Date <br /> Final Inspection Approval Signature Date T <br />