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- Engineering and Development Services ,`� •q <br /> ' 1. PD Box 547, Anacortes,WA 9E2211 �`� �F+ <br /> Tim 360293,1220 FAX 36Q293.1 P3B ' <br /> 4 EMAIL: engineering@cityofanacortes.o g v <br /> "�� rs7 - RIGHT-OF-WAY PERMIT APPLICATION <br /> i=...�-� '- RCW 1 S.122 Underground Utilities '• <br /> P <br /> CALL BEFORE YOU DIG m (EDO 424-5555 Q P , <br /> ----,-,-,-,-...- <br /> Applicant shall submit application 5 days prior to start of Work and application shall include: ' <br /> --_=�? ❑ (1) Payment of assessed fee • <br /> 0 (2) Drawing iIlustraiing proposed work.and its location. See checklist on <br /> Page 2 of 2. • <br /> 0 -(3) Liability insurance CG 2026 or similar. City named as additional insured~ Minimum $t,0DQ,000 each <br /> occurrence,$2,00Q,00O general aggregate and $2,000,000 products-completed operations aggregate limit <br /> 0 (4) Proof of both state and city business licenses <br /> 0.—( -Performance-Bond-==Construction cost X'150%-before work-begins <br /> t ) Encroachment Agreement Required To be completed by City: 0 Yes i 'ND 1 <br /> . Site Address: City Approved Exemption 0 Yes 0 No <br /> L� i�-t Q�GE C' If Dvt �� EDEN ASSIGNED-PERMIT NUMBER: <br /> . Z0\ - 260 ` _ 4 <br /> Parcel No. p 5--tsi <br /> $ d 7 - <br /> Owner information (Reo> r#red) Contractor Irr formation (Required) . <br /> Name Name <br /> 9� X� Ve C- ry /1/1/WJALAR.I. S Slime- <br /> d, +tom <br /> Address 3 Ct L 6 J AC/& Address -s 4� <br /> city • City <br /> Phone . Phone <br /> 15 <br /> _I�!-Ern ail <br /> Address at a9 J V ( 1 , l 'r41, Address 5` i e) 0 i wt S'I-✓vc..4t)ve5 .Gbt,'" <br /> Work Includes (check all that apply) <br /> 0 Curb Cut I] Water Yi Sewer ❑ Storm ❑ Street Cut 0 Sidewalk 0 -Phone ❑ Dther <br /> IDescribe Work to be Performed: (Notification of Utility Companies is Required) - <br /> 7 .. <br /> Tap ;eta cle_ 5-e Cle: 5/ mr of p r o p +✓t/'ly !hie. . - <br /> • <br /> ',v '•'-1 i-'1 ;-1 -1- <br /> • ri -1- I-.., 1 1 I it <br /> • <br /> •-/� <br /> • C. ,4pp I Signature D a . <br /> i ... - I-7 it <br /> signature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- :`;.. `s'1 .- ", <br /> loyees and volunteers harmless from any and all claims, injuries, damages, lasses or suits including attorney — el- i-'' "= ' <br /> v ansing out of or in connection with activities or operations performed by the Applicant or on the Applicants behalf ..-1.. ,- ` :A <br /> out.of issuance of this Permit,except for injuries and damages caused by the sole negligence of the City. 4:1 ;=! '= <br /> I--1 !-- <br /> 3plicant Sig hture Date , --'••.J 1 <br /> 1`-1 I -I o <br /> 1 T: <br /> Final inspection Approval Signature Date . ; ';' `. <br /> • I....) t".,} a, <br />