HomeMy WebLinkAboutROW-2010-0059 - Engineering snd Development Services
PO Box 547,Anacortes,WA 98221
TN:360.293.1920 FAX 360.293.1938
' 4ri' EMAIL: engineering@cityofanacortes.org v
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RIGHT-OF-WAY PERMIT APPLICATION
RCW 19.122 Underground Utilities .,�.
CALL BEFORE YOU DIG -(800)424-5555 '4p�'�'"j•p'
Applicant shall submit application 5 days prior to start of work and application shall include:
❑ (1) Payment of assessed fee
0 (2) Drawing illustrating proposed work and its location. See checklist on '
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(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.,
11 (4) Proof of both state and city business licenses
❑ (5) Performance Bond=Construction cost x 150% before work begins
❑ (6) Encroachment Agreement Required I i •
Site Address: City Approved Exemption ❑ Yes ❑ No
EDEN ASSIGNED PERMIT NUMBER:
Parcel No. - (® -
Owner Information (Required) Contractor Information (Required)
Name Name
Address � Address
City City 2�
C , Phone Phone
Email Email ��ll
Address Address � � � Uj • �el
Work Includes(check all that.apply)
Curb Cut Water ❑ Sewer `X Storm Street Cut ❑ Sidewalk ❑ Phone ❑ Other
Describe Work to/be Performed: (Notification of Utility Companies is Required)
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Clty,Ap` val Signature Date ;;3
By si at "e below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials,em-
plo es d volunteers harmless from any and all claims, injuries,damages, losses or suits including attorney fees, C-1 r
a 'sing to in connection with activities or operations performed by the Applicant `B;or on the Applicant's behalf ' '`'
P
ut o I " ce o this Permit,except for injuries and.7dmages caused by the sole negligence of the City.
1 Ap t gn r Date
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Final Inspection Approval Signature Date {
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NON-REFUNDABLE PERMIT FEE: (To Be Completed by City)
❑ :Curb. Cut $50.00
❑ Street Out $50.00
Inside Travel UVay $50.0-0
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❑ Outside Travel Way $20.00
❑ Sewer Inspection Fee $50.00
❑ Sewer Re-Inspection Fee ' $25.00
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.;
Draw the plan to a standard Engineering Scale[1"=10', 1'"=20"etc.]on a minimum size sheet of 8 Yz 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.
_ e 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/gutter, sidewalk,driveways, planting strips.
• 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 http://mutcd/fhwa.dot.aov). 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.
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