HomeMy WebLinkAboutPermit File ROW-2019-0221 1515 12th Street Y O City of Anacortes Invoice/Permit#: ROW-2019-0221
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904 6th Street Applied date: 12/23/2019
'16,60611eliwor P.O.Box 547
Issue date:
0 Anacortes, WA 98221-0547
Expire date: 12/22/2020
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Job Address: 1515 12TH ST Permit Type: Right of Way Permit
ANACORTES WA 98221-2110 Project:
APN: P58027
Remarks: Emergency repair to sewer line from house into alley right-of-way. Justin already inspected the emergency repair, and all
o.k. and covered up.
Owner: DARWIN HELMUTH Contractor: FISHER EXCAVATING LLC
Address: 812 FAVE Address: 4501 SAN JUAN AVE
ANACORTES WA 98221-1434 ANACORTES WA 98221-1123
Phone: (360) 630-7338 Phone: (360) 708-2016
License#:
General Information: Fees:
Cable N Inside Traveled Way 50.00
Inside Traveled Way N Total Calculated: 50.00
Outside Traveled Way N Deposits/Receipts: 0.00
Culvert N
Natural Gas N Total Due: 50.00
Power N
Telephone N
Sewer Y
Water N
Storm N
Street Cut N
Sewer Reinspection N
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED. I
HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT.ALL PROVISIONS
OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SP. -G,JFIED HEREIN OR NOT, THE
GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE P:.fISIO OF ANY OTHER STATE OR
LOCAL LAW REGULATING CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
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SIGNATURE OF OWNER OR AUTHORIZED AGENT IS.UED :'�-
Permits and Insp...-ROW-2019-0221 -2019
019519-0048 Carla Br... 12/23/2019 11:02AM
11124- FISHER EXCAVATING LLC
ROW-2019-0221 Right of Way Permit
Payment Amount: 50.00
Transaction Amount: 50.00
02CASH:
Engineering and Development Services ,`l�,0 .Q
PO Box 547, Anacortes,WA 98221 , ,
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f r'' tk TN: 360.293.1920 FAX 360.293.1938 ' /:.: ?.
: fir. EMAIL: engineering@cityofanacortes.org v tt e�
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w77.TSi''-j;- • , ` Cr) R[GHT-OF-VIIAY PERMIT APPLICAT[ON
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`', ,c' RCW 19.122 Underground Utilities a
CO. - CALL BEFORE YOU DIG - (800) 424-5555 '1 •p•W •Q'
Applicant shall submit application 5 days prior to start of work and application shall include:
0 (1) Payment of assessed fee
❑ (2) Drawing illustrating proposed work and its location. See checklist on
Page 2 of 2. r", 11 g ] g \V-/ El.
❑ (3) Liability insurance CG 2026 or similar. City named as additional insured. Minimum $1,000,000 ibh
occurrence,$2,000,000 general aggregate and $2,000,000 products-completed operations agg g�'ate ,
❑ (4) Proof of both state and city business licenses
i
O (5) Performance Bond—Construction cost x 150% before work begins k
❑ (6) Encroachment Agreement Required To be completed by City: 0 Yes 0 No 'CITY OF ANACORTES
Site Address: City Approved Exemption ❑ Yes 0 No
,15- / / �. S---r- EDEN ASSIGNED PERMIT NUMBER:
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Parcel No. -
Owner Information (Required) Contractor Information (Required)
Name Name
Z7MhiA-' /Ie.--z- l 'z7/' ii Lr
Address . Address 2 Ae-e- b,76 cit- 2"
City ,417 City
Phone ,i Phone
e 7U/- 21/i
Email Email
Address Address 7 1 �� e�.�o,�� �Ae./ c-�
Work Includes (check all that apply)
❑ Curb Cut ❑ Water 14 Sewer ❑ Storm ❑ Street Cut 0 Sidewalk El -Phone ❑ Other
Describe Work to be Performed: (Notification of Utility Companies is Required)
/etXl Cdf ›" 2Ji F 447 /'1t5, (--- -a d #/, .
/1/e ry _e/t (j Pepiti---)
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____) i
City Approval Signature Date
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.
i —,4--2 ..1 L / 2 2, ,
Applicant Signature Da
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Final Inspection Approval Signature Date . {
,
0
NON- REFUNDABLE PERMIT FEE: (To Be Completed by City)
❑ Curb Cut $50.00
D Street Cut $5O O
0V . Inside Travel Way ( $50.00 ,.!
❑ Outside Travel Way $20.00
D 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 1/2 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.
e 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.
o Erosion Control Plan.
® Traffic Control Plan per current MUTCD (See standard drawings at http://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.
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