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Engineering and Development Services <br /> PO Box 547,Anacortes,WA 98221 <br /> Telephone 360.293.1920 <br /> Fax 360.293,1938 <br /> E-mail ennineerinoacitvofanacortes.orq <br /> RIGHT-OF-WAY PERMIT APPLICATION <br /> Submit this application with payment at least five days before the work starts. Please <br /> complete both sides of this form. (City completes shaded sections.) <br /> SiTE <br /> LOCATION: I 1 ' I` • „» <br /> OWNER INFORMATION CONTRACTOR INFORMATION <br /> Name 'I ( ( ��� t ���� Name ' t'al C <br /> Address 1‘k 0 1l-VIA Address <br /> City NiNr.G' -0 f - City <br /> State tA.) AZip + L'> State Zip <br /> Telephone '2,01 ? - l Telephone <br /> License Number <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> ❑ Curb Cut ❑Water ❑ Sewer ❑ Storm Cl Gas ❑ rwalk <br /> El Street Cut ❑ Phone ❑ Power El Cable CI Culvert v --� <br /> t • <br /> Describe Work: CZ a-,t`, Z. (% `� P` k;% C-'L 1 "' ;r <br /> r l T N (AA ii r> c r 6," T H to f i.44/12-- <br /> (JAL- v�;i)G A)Et'I- / /7 f <br /> �d ax ale{ r-a t° wu <br /> '<Stj i P ,If <br /> 41111101,10. � � F r� - � �'�<��'.a:- ^v "�'�r r s'.y � � ii a.� �'v°r� g� <br /> r, � IAT k �I f - r t 1� d5 E i'l 3i, s6 Y <br /> - - <br /> Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right-of- <br /> way must be bonded. The applicant and owner must use warning signs, traffic control, and barricades as <br /> necessary to ensure public safety in the work area. The applicant and owner must restore the right-of- <br /> way to previous condition. The applicant and owner are liable for dame lc and private property. <br /> \\, <br /> its nr a J. t J <br /> Applicant ignature Date <br />