8/1/2019 1:01:42 AM
7/31/2019 4:46:14 PM
Right of Way Permit
3806 Q AVE
Applicant Name (LN, FN)
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x Engineering and Development Services t�0 �'_ .Q <br /> ' , , PO Box 547, Anacortes, WA 98221 ° <br /> e <br /> ..,, ... <br /> ' TN: 360.293.1920 FAX 360.293.1938 �' <br /> r < : .... <br /> ' EMAIL: email@example.com ,v h <br /> s .' RIGHT-OF-WAY PERMIT APPLICATION Y <br /> RCW 19.122 Underground Utilities <br /> CALL BEFORE YOU DIG `y'q�'`��'- (800) 424-5555 p•W <br /> Applicant shall submit application 5 days prior to start of 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 /> Li (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 /> 1 : (4) Proof of both state and city business licenses <br /> I., (5) Performance Bond—Construction cost x 150% before work begins <br /> H! (6) Encroachment Agreement Required To be completed by City: i1 Yes i 1 No <br /> Site Address: / y City Approved Exemption Li Yes Li No <br /> EDEN ASSIGNED PERMIT NUMBER: <br /> 'g ZCeI (1 _ 00r 2— <br /> Parcel No. p .5"., 87 <br /> / <br /> Owner Information (Required) Contractor Information (Required) <br /> Name Name 't 4-I � Z` —0N Coo. � G7f 4i oil <br /> 9711,1kil'it., I r..� e Da j 0 AIv. CJre✓ <br /> Address Address <br /> 3 g"06 a 0 VIII et, iti-e i/il R-d <br /> City A41-/v4. City <br /> >. WA ,cediNO tr .VA,4.04A11, <br /> Phone it4-3 <br /> 0e 65'3 Phone 360 6 `1 ` 65'1-5 <br /> Email I .f Email <br /> Address ,&1e k wi e G`etioi .c,, Address „ �-c>` 1 f <br /> / Stf 1 'I'll' 4.1-olI L t' iC tt�� <br /> g <br /> Work Includes (check all that apply) <br /> 1 Curb Cut 11 Water Sewer L Storm -J Street Cut it Sidewalk 11 Phone 1 <br /> 1 Other <br /> Describe Work to be Performed : (Notification of Utility Companies is Required ) <br /> iiiv 41 I c vrvY:&i e 14 /CIe.. Fa414H R � Gi V e :. c ) S s . .c <br /> 1,/i 3//? <br /> ty ppro I ',ignature Date <br /> B gnature b -low Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- <br /> p gees and v•lunteers 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 I his P mit, e ept or injuries and damages caused by the sole negligence of the City. <br /> dI <br /> i ',)t 'f? <br /> Applic t Signature /.--..-- Date <br /> Final Inspection Approval Signature Date It <br />
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