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> .. _?1 2 ti 04" 0001 05 ....s.e , ?0t. i` 002 2 5=.! <br /> `,'rmi.'m F. _._ 007524 i20.00 <br /> Engineering and Development Services <br /> " rz PO Box 547,Anacortes,WA 98221 <br /> Telephone 360.293.1920 <br /> Fax 360.293.1938 <br /> E-mail enoineeringt citvofanacortes.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 P'E,'� R='Ail°IT .. . . <br /> LOCATION: t� .a0 .14 tOlifiEtZ hV "" 2 0 2_ <br /> OWNER INFORMATION CONTRACTOR INFORMATION <br /> Name Vyjjyt. VA GI Name LeAL <br /> Address 222o Z Li h Address <br /> City r-11(ZQ.(®( \S City <br /> State Lipa Zip cua Z State Zip <br /> Telephone (3 .0U) 420 3tEc Telephone <br /> License Number <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> ❑ Curb Cut ❑ Water ❑ Sewer ❑ Storm ❑ Gas ❑ Sidewalk <br /> ❑ Street Cut ❑ Phone ❑ Power ❑ Cable ❑ Culvert <br /> Describe Work: ip "+ k,..a�tt '; fTha,� � .� i� 1 Ls. t— <br /> PERMIT TYPE <br /> 0 Curb Cut$50 0 Street cut`$50 ❑ Inside Traveled:Way$50 Outside Traveled Way$20 <br /> SiPECiIAL;RE:Q.U:IRE.MENTS _ - <br /> Galf 1,$0©424 5555two business days beftxre you dig. <br /> ._- <T . <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. <br /> - t5401.q fp" i\IAM /\)61 5k01143) bl <br /> City App ication Approval Sig ' cure;', _ ;:; Date Applicant Signature Date <br />