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<br /> Enginee.rin.g and Development.Services
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<br /> PO Box 54.7, Anacortes,WA 98Z21
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<br /> TN: Nvs4'
<br /> . .. .„.-„,„ .. 35E1.2 n:1920 FAX 33029a.1238
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<br /> EMAIL enginesng@cityoianacortes.ang
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<br /> R1GHT-OF-WAY PERMIT APPLICATION
<br /> RCW 19.122 Underground Utilities
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<br /> 4t1---6--Fs--4- . CALL BEFORE YOU DIG - (8D0) 424-5555 4•P•*• '
<br /> Applicant shall submit application 5 days prior to start of Work and application shall include:
<br /> O (I) Payment of assessed fee '
<br /> E (2) Drawing illustrating proposed work.and its location. See checklist on
<br /> Page 2 of 2. •
<br /> O -(3) Liability insurance CG 2026 or 51miiar. City named as additional insured. Minimum $1,000,000 each
<br /> occurrencerV,D00,0D0 general aggregate and $2,000,000 products-completed operations aggregate limit
<br /> D (4) Proof of both state and city business licenses
<br /> O (5) Performance Bond—Construction cost x '150% before work begins
<br /> D (6) Encroachment Agreement Required To be completed by City 0 Yes 0 No
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<br /> Site Address: /141,6 7 2,
<br /> 711/e:. City Approved Exemption 0 Yes D No
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<br /> EDEN.ASSIGNED.paRmirr NUMBER:. - - 14.,_r..)V\I . 2._0/ 9
<br /> Parcel No.
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<br /> Owner RR-don/lotion (Required) Contractor information (Required) .
<br /> Name Name ,, ''. •
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<br /> Address Acidt-ass .
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<br /> City ,,)._
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<br /> Phone Phone
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<br /> Email / A • a. -Email . '
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<br /> Address 'ILie,0071 ;/ "( A.-4 6/4) f;) . -; c • e 0,ill/ Address
<br /> Work Includes (check all that apply)
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<br /> Curb Cut D Water il Sewer Storm 1:1 Street Cut D Sidewalk D •Phone D Other
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<br /> . . Describe Work to be Performed : (Notification of-Utility Companies is Required) -1
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<br /> lEIy igna ,re below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- 4,4
<br /> pp ees drid volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees,
<br /> arising out of or in connection witt)Aptivities or operations performed by the Applicant or on the Applicant's behalf ,il-t -1•1 1:11:t :5E:
<br /> out.of issJipnce of ; Pe ' etedPt for injuries and damages mused by the sole negligence of the City. • 071 ii::
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<br /> Final inspection Approval Signature • .Date
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