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_25':'0+j-1 0003 09 <br /> /1_{ ;2005 002 102 <br /> t F 'Y_ 006656 $5O,0f= <br /> Engineering and Development Services <br /> PO Box 547,Anacortes,WA 98221 <br /> < � a Telephone 360.293.1920 <br /> </da c P <br /> Fax 360.293.1938 <br /> 5 ', E-mail engineerinq(a�cityofanacortes.orq <br /> > a <br /> RIGHT-OF-WAY PERMIT APPLICATION <br /> Submit this application with payment at least five days before the work starts. Please <br /> complete both sides of this form. (City completes shaded sections.) <br /> SITE I <br /> LOCATION: tor tor3.36 CAS Cc3t,lt NUMBER: i { �` Y l <br /> OWNER INFORMATION CONTRACTOR INFORMATION <br /> Name (-)p u Name <br /> Address 60 30, Gty-"mil` / 6.6 Lt Address <br /> City ANA(t)fi t' S City <br /> State /A Zip ! g Z I State Zip <br /> Telephone 3(2C)-24 3 _c 3 770 Telephone <br /> License Number <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> {Curb Cut ❑ Water ❑ Sewer 1 Storm ❑ Gas ❑ Sidewalk <br /> ❑ Street Cut ❑ Phone ❑ Power ❑ Cable ❑ Culvert <br /> Describe Work: f�;� e c � ri 1 �'1 I (� {� `#-{� (r�t � -�-G<L},�. <br /> `'- ((i (( 5 !4e iYr 110 t 4-Z) .31 UPet fic %fit`'ern uia.4 er <br /> c)'T k a k e.. t'v ci Of S e <br /> •? R�ITp TP <br /> tt jT•1; -t <br /> rP t; a ❑$tr .et cut ts��+`{yy� = a r 44 W y P s [ ��- ve ecl Way ? <br /> c k. .F_ �- 9 T'; '� �3�..'�>di. '.�*n'-a� a..'w ���� ? k� '� <br /> t a/ r4 �1##111:t 0S� #*r© e is <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 /> = F ,�� # i ��-w-F nil.,' <br /> 7-„, <br /> .-/q os- <br /> w4etivt: —.,0 <br /> Applicant Signatu Date <br />