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c d s1)4 Lk-c)- P=1-6' 1010 <br /> Engineering and Development Services ft"t? 4 <br /> PO Box 647,Anacortes,WA 98221 Q� -jtp <br /> TN: 360.293.1920 FAX 360.293.1938 <br /> ```' EMAIL engineering@cityoranacortes.org <br /> RIGHT-OF-WAY PERMIT APPLICATION <br /> RCW 19.122 Underground Utilities <br /> CALL BEFORE YOU DIG - (800) 424-5555 'I •p;w'- <br /> Applicant shall submit application 5 days prior to start o#work and application shall include: <br /> (1) Payment of assessed fee <br /> ' (2) Drawing illustrating proposed work and its location. See checklist on <br /> Page 2 of 2. <br /> (3) Liability insurance CG 2026 or similar. City named as additional insured. Minimum $1,000,000 each <br /> occurrence,$2,000,000 general aggregate and $2,000,000 products-completed operations aggregate limit. <br /> (4) Proof of both state and city business licenses <br /> (5) Performance Bond—Construction cost x 150% before work begins <br /> - (6) Encroachment Agreement Required To be completed by Qity: : I Yes = ° No <br /> Site Address: (I 13 r /*-V6 City Approved Exemption : Yes - No <br /> ( t S , A fl CCod 14e S fit9A EDEN ASSIGNED PERMIT NUMBER: <br /> Parcel No. y, jU1�1/ - v� is 0(� <br /> Owner Information (Required) Contractor Information (Required) <br /> Name Name David g L knghee Sp sr ce-�-' Roger- i ejj <br /> O7eSG-i- <br /> Address 5 ! 13 r e.�ri D ,•` Address P O eX ) '4 <br /> I <br /> City Yakvn a ) tit/} 1 U 6 o 2-- City 1J( r {119 f-01 WA � N3 3 <br /> Phone 57) r� c,_3 s— Phone 64 <br /> 0 <br /> Email"' f� ( Email <br /> Address 5 C4fC hf e'. S(j21 (er(X c t re , oft- <br /> Address <br /> Work Includes (check all that apply) <br /> Curb Cut ` ` Water 11 Sewer 11 Storm Street Cut Sidewalk Phone Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> f -firPf 1)(11141e-sr- Ole <br /> I J 14°1:^n ft lit CO tree 44-n hi <br /> City pprov S nature Date <br /> By si ature below Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- <br /> ployees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, <br /> arising out of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf <br /> out of issuance of this Permit, except for injuries and damages Jcaused <br /> �by the sole negligence of the City. <br /> p L 6/— .� i.'/ <br /> A 1"canit`lature ��� Date <br /> Final Inspection Approval Signature Date �` <br />