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<br /> ar Engineering and Development Services
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<br /> :: ` PO Box 547,Anacortes,WA 98221
<br /> ' Telephone 360.293.1920
<br /> Fax 360.293.1938
<br /> *` ,. 1.v°, E-mailc�ail engineerinqc tvofana ortes orrg
<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 - ,> _$ -:vg<="'
<br /> 1 k 041 -.0
<br /> LOCATION: 311 jet°( 'E 1 e .. .,
<br /> OWNER INFORMATION CONTRACTOR INFORMATION
<br /> Name hod " )MoC.,K Name
<br /> Address 13C l I-7 Address
<br /> City 4schAtioiltys City
<br /> State L)tr Zip i State Zip
<br /> Telephone r *+ .15 tfi Telephone
<br /> License Number
<br /> PROJECT INFORMATION
<br /> Work Includes (check all that apply)
<br /> X Curb Cut ❑Water ❑ Sewer ❑ Storm ❑ Gas ❑ Sidewalk
<br /> ❑ Street Cut ❑ Phone ❑ Power ❑ Cable ❑ Culvert
<br /> Describe Work: 0\16�,. e '13 Lj 'S\4 v`) �JL. Pik,\V (�
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<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 damage to public and private property.
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<br /> Applicant Signature Date
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