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Engineering and Development Services 40 q <br /> 611 <br /> YOfi PO Box 547,Anacortes,WA 98221 p‘ t''J. <br /> TN:360.293.1920 FAX 360.293.1938 V� n <br /> EMAIL: engineering@cityofanacortes.org a 4 <br /> L � RIGHT-OF-WAY PERMIT APPLICATION <br /> r,(4, RCW 19.122 Underground Utilities <br /> `'CO CALL BEFORE YOU DIG -(800) 424-5555 4•p•W•Q' <br /> Applicant shall submit application 5 days prior to start of work and application l � ht d ,, 4vt 4;�,; I <br /> ✓ (1) Payment of assessed fee <br /> C (2) Drawing illustrating proposed work and its location. See checklist on <br /> Page 2 of 2. ) 1 <br /> FEB O 1 2019 <br /> L (3) Liability insurance CG 2026 or similar. City named as additional insured. Minimum$1,1:i,300 each <br /> occurrence,$2,000,000 general aggregate and$2,000,000 products-completed operation.rtgr t pith► ;oj::t `V• <br /> L (4) Proof of both state and city business licenses <br /> C (5) Performance Bond—Construction cost x 150% before work begins <br /> C (6) Encroachment Agreement Required To be completed by City: 1 Yes I No <br /> 1 <br /> Site Address: J� c��j City Approved Exemption 1 Yes I No <br /> I 1 l I I 0 S T rrt� '� ,Oa. I, .2-J EDEN ASSIGNED PERMIT NUMBER: <br /> COW - ZO1ci - 00 / `! <br /> Parcel No. p 55.9 (07 <br /> Owner Information (Required) Contractor Information (Required) <br /> Name 7 <br /> L7/ u6 b ti�2 Name - F <br /> Address /7/// T Address � `E <br /> City City <br /> 4144C® -FT A Pc-ci7 <br /> Phone / 0) zl _ Z L/ / Phone 3(.0 29 Z0` ' <br /> Email (4er‘ <br /> J /, / !,, Email '-1 l <br /> Addressc C�CO/hCgr 7` NE� Address aLie( 5 e �l'Y1( "(�P�7 <br /> Work Includes (check all that apply) <br /> Curb Cut L Water U Sewer Storm Street Cut �C. Sidewalk L Phone L Other <br /> Describe Work to be Performed: (Notification of Utility Companies is Required) <br /> 2.E P uA-CEm E- J T 0 t k)1-°t fc 5U P PruN Li n)E P t2Dm C i ►mil al Ala <br /> i 0 H'OX Se b v To L,L— h t&.. l,JA-C--12 l A K., 15 5 VS Pe--C-�-1 <br /> I)rU . Sioc tcrIC <br /> c '// J/ 9 <br /> it Approv Si ature Date <br /> B s' nature elow Applicant concurs that the Applicant shall defend, indemnify and hold the City, its officials, em- <br /> p yes and volunteers harmless from any and all claims, injuries,damages, losses or suits including attorney fees, <br /> ar9 mg out of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf <br /> out of is ance of this Permit, except for injuries and damages caused by the sole negligence of the City. <br /> r ,.� J-/- /9 <br /> pplicant Signa re Date <br /> Final Inspection Approval Signature Date { <br />