HomeMy WebLinkAboutROW-2010-0085 - ' Y Engineering dnd Development Services ♦��� .qC
�!S ��, PO Box 547,Anacortes,WA 98221Q �n
TN:360.293.1920 FAX 360.293.1938
EMAIL: engineering@cityofanacortes.org
RIGHT-OF-WAY PERMIT APPLICATION a
RCW 19.122 Underground Utilities
4 COg CALL BEFORE YOU DIG -(800)424-5555 '4•p W.Q' g
Applicant shall submit application 5 days prior to start of work and application shall include:
❑ (1) Payment of assessed fee
❑ (2) Drawing illustrating proposed work and its location. See checklist on
Page 2 of 2.
❑ (3) Liability insurance CG 2026 or similar. City named as additional insured. Minimum$1,000,000 each
occurrence,$2,000,000 general aggregate and$2,000,000 products-completed operations aggregate limit.
❑ (4) Proof of both state and city business licenses
❑ (5) Performance Bond—Construction cost x 150% before work begins
❑ (6) Encroachment Agreement Required T m Yes Li No
Site Address: City Approved Exemption ❑ Yes C No
EQgN ASSIGNED PERMIT NUMBER:
Parcel No.
Owner Information(Required) Contractor Information (Required)
Name Name O w S67_-1/t C_(93 C L C_
Address VV Address
City City I
Phone 47U Phone ?��9C✓ CD Ll7
Email l 1 Email
Address Address
Work Includes (check all that apply)
❑ Curb Cut ❑ Water 11 Sewer ❑ Storm ❑ Street Cut ❑ Sidewalk ❑ Phone ❑ Other
Describe Work to be Performed: (Notification of Utility Companies is Required)
�P
7 Aa /J_/_
ity Approval Signature Date 1.®
By signature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials,em-
ployees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees,
arising out of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf
out of issuance of this Permit,except for injuries and damages caused by the sole negligence of the City.
Applicant Signature Date
i
Final Inspection Approval Signature Date
NOW REFUNDABLE PERMIT FEE: (To Be Completed by City)
Curb Cut $50.00
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❑ Street Cut $50.00 !.
❑ Inside Travel Way $50.00
i
❑ Outside Travel Way $20.00
❑ Sewer Inspection Fee $50.00
❑ Sewer Re-Inspection Fee $25.00
I
TOTAL FEE ASSESSMENT $
A Site Plan (to scale) must be attached that include all of the following:
This checklist will aid the applicant in preparing a site plan. Permits that require installation of substantial improve-
ments may require plans drawn and designed by a licensed engineer. Please check with City staff prior to submit-
ting your application. j.
• Draw the plan to a standard Engineering Scale[V=10', V=20"etc.]on a minimum size sheet of 8'/2 x 11
and a maximum size of 11x17.
• Include the owners name,the parcel ID number,site address, north arrow, drawing scale and date.
• Include the contractor's name,address and phone number.
_ • Existing Right-of-Way lines,property lines,edge of pavement, curb/gutter, sidewalks, driveways and plant-
ing strips with dimensions between each.
• Adjoining street name(s)to the reference property.
• All existing public and private utilities in the area of the proposed project(Water, Sewer, Storm, Phone,TV,
Gas and Power dimensioned to the edge of pavement,curb/ utter, sidewalk, driveways, planting strips.
), 9 9
• If applicable show easements,critical areas such as streams,wetlands and steep slopes.
• Proposed new construction.The proposed improvements shall be shown in heavier line type than the ex-
isting information
• Dimension the proposed new construction to the edge of pavement,curb/gutter, sidewalks,driveways,
planting strips, or another identifiable site feature that will help identify the proposed improvements in the
field.
• Erosion Control Plan.
• Traffic Control Plan per current MUTCD (See standard drawings at htto://mutcd/fhwa.dot.gov). If the work
requires any lane or street closures,the City of Anacortes Public Works Inspector must be notified a mini-
mum of 48-hours prior to scheduled work for proper public notification by the City of Anacortes.
Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right-of-way must be
bonded.. The applicant and owner must use warning signs,traffic control, and barricades as necessary to ensure
public safety in the work area. The applicant and owner must restore the right-of-way to previous condition. Perma-
nent restoration may include overlays of portions of the right-of-way and restoration of landscaping which have been
disrupted by excavation work. The applicant and owner are liable for damage to public and private property.
Page 2 of 2
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City of Anaaortes
1 Finance
1020903-1 L-/28/2010 BR1 T9
Wed Ju128,2010 11 :27AM Tr'an >#33-33
Name: NORTHVJESi SERVICES LLC
Addr: 1014 4?H ST ANACORTES,WA 9822115
33 $50.00 8000 - Per,mir Fees
* Customer #: 007192
* Permit #: ROW-201Q
1 ITEM(S): TOTAL:. $50.G't_!
Check (04736) PAID $50,00
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