HomeMy WebLinkAboutPermit File 1509 14th Street Ih
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Engineering and Development Services r 4IG>. 0.tPO Box 547,Anacortes,WA 98221TN:360.293.1920 FAX 360.293.1938 4� EMAIL: engineering@cityofanacortes.org a jyt �C
�. � RIGHT-OF-WAY PERMIT APPLICATION ,� A,
4CO ` ' CALL BEFORE YOU DIG -(S00)424-5555 . '4•p�;W Q'eq RCW 19.122 Underground Utilities _
App- ant shall submit application 5 days prior to start of work and application shall include:
LI,Lrayment of assessed fee
2) Drawing illustrating proposed work and its location. See checklist on
Page 2 of 2.
H (3 1 iabil'ty insuranra G8 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.
Proof of both state and city business licenses
❑ ( PPrfnrmance Bond—Construction cost x 150%before work begins
❑ (6) Encroachml LIAgreement Required To be completed by City:. ❑ Yes ❑ No
Site Address: City Approved Exemption❑ Yes ❑ No
�'` EDEN ASSIGNED PERMIT NUMBER:
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Parcel No. ZDi -�0 L I
Owner Information (Required) Contractor Information (Required)
Name \ ry Name /
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Address Address �/ �// ��
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Email Email At're,reel/A9
iAddress Address 71l��r� 4.�?./U C' G
Work Includes(check all that apply) !
❑ Curb Cut C Water IX. Sewer D Storm ❑ Street Cut 0 Sidewalk ❑ Phone 0 Other
Describe Work to be Performed: (Notification of Utility Companies is Required)
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ty Approval Signature D/z ,/,i
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By signature below Applicant concurs that the Applicant shall defend,indemnify and hold the City,its officials,em- zi
ployees and volunteers harmless from any and all claims,injuries,damages,losses or suits including attorney fees, • " i`':'
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arising out of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf r.
out of iss ance of this.Pe it,except for injuries and damages caused by the sole negligence of the City. Lfl ----
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Final Inspection Approval Signature Date . • { '`')
Permit Fee Estimate
Current Date December 21, 2011
Permit Type Right of Way Permit
Permit# ROW-2011-0204
'Address 1509 14TH ST
ANACORTES WA 98221-2133
Fee Description Fee Amount
Inside Traveled Way $50.00
Outside Traveled Way $0.00
Sewer Reinspection Fee $0.00
Total $50.00
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, CITY OF ANACORTES
BLDG. 0 PLUMBING ❑ MECHANICAL 0
PERMIT ,° 4
I, 'Telephone2935173 - -'
,D iC 6
': ANACORTES, WASH. _ DATE ' % / �19 .5� �
"�
k' PERMISSION IS HEREBY GRAN_ TED TO: - -
0WNER ,90.M4651:5d inc 1.?n4t'�LST
STREET . . .W; ;t1
1:.
':ADDRESS Cr
LOCATION WHERE WORK IS TO BE DONE ,{
CONTRACTOR it t ..y eo duo Yu y
' Li
.; TO ERECT ❑ INSTALL ❑ OR REPAIR q Li
_'i IN THE FOLLOW G MANNER: -+`=',F'•' .r- •-40'Ci'`' a +45 r`-a.,..ic '
i.- bat . .^,r..f -„%'
F:-_ - PERMIT EXPIRES ONE YEAR FROM DATE ISSUED N
PLANS FOR CONSTRUCTION WEREWERE NECRI*SUBMITTED
t;,WORK TO BE DONE BY OWNER;; CONTRACTOR ❑
ir RECEIPT OF FEES IS ACKNOWLEDGED AS FOLLOWS:
-
APPROXIMATE VALUE
'' TYPE OF WORK PERMIT FEES ,
I' ISSUING "
BUILDING xr ;0 COfir tF I
Ph GAS PIPING
y
PLUMBING AND W.S. - - - ' -
F SEWER CONNECTION INSP. -
�; MECHANICAL
PLAN CHECK FEE , _ i
—Lill LI gr
h. h TOTAL I p, ?Li CO' f2 S -"t;
t' LEGAL DESCRIPTION -
! I. / CITY INSPECTOR
CITY OF ANACORTES
BLDG. 011 PLUMBING ❑ MECHANICAL 0
PERMIT r,.. -: - ten
Telephone 293-5173 1
`
p ANACORTES, WASH. DATE N. ' 19
I
FI PERMISSION IS HEREBY GRANTED TO: - s,
OWNER, _2 a;c- /ill-:: ,-It,.. A.14 nrepL :...e.
': ADDRESS r( -G 1 cif :--
E - LOCATION WHERE WORK IS TO BE DONE
r, CONTRACTOR Our AlLe t"L> ,I
TO ERECT d- INSTALL 0 OR REPAIR ❑ '
- IN THE FOLLOWING MANNER: =jt '- C.4- -Cr:- •=a !'=„'ffs C . ' 14,0- '1: 1
4
' PERMIT EXPIRES ONE YEAR FROM DATE ISSUED s
WERE NOT 6-
k;.i PLANS FOR CONSTRUCTION SUBMITTED
WERE ❑
i WORK TO BE DONE BY OWNERX CONTRACTOR ❑ 1
O RECEIPT OF FEES IS ACKNOWLEDGED AS FOLLOWS:
i'
Li hi TYPE APPROXIMATE VALUE
Id " PERMIT FEES�'i OF WORK
I I ;'':IIIISUING
" : '![BUILDING 'i .ICs' Cu 'p =Y;:.
IGAS PIPING
IL ' 'iFALUMBING AND W.S.
'tt_ I'kSEWER CONNECTION INSP.
IMECHANICAL
I MP,LAN CHECK FEE
i,, !',MISC. 1 .
TOTAL OO' u r ; > .
'W pAL DESCRIPTION
ti- . -° - -e-54
CITV INSPECTOR _`_T-
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