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• <br /> Engineering and Development Services <br /> ,.Y ��� PO Box 547,Anacortes,WA 98221 <br /> Telephone 360.293.1920 <br /> Fax 360.293.1938 • <br /> ' _..: E-mail engineering@cityofanacortes.org <br /> S.: '' RIGHT-OF—WAY PERMIT FRANCHISE , <br /> APPLICATION <br /> Submit this application with payment at least five days before the work <br /> starts. Please complete both sides of this form. (City completes shaded <br /> sections.) <br /> SITE PERMIT I <br /> LOCATION: NUMBER: 1 ,6\ikr_ 20161 -002/ <br /> OWNER INFOR ATl©N CONTRACTOR INFORMATION <br /> Name glide/ lty Name CPT Pt LI.hA.fai.'1^ I-f ad i3 het` <br /> J <br /> Address 1P)P 1IN U- Address Z G of '�co.(�txc9 . <br /> City kawipe./ :) CityyY C,U4-I-f/-e_rv;rV . <br /> State L//}- Zip 1y221 State ;k./Pr Zip I v _1 ) <br /> Telephone Telephone k,90 L-10-Pte SI,-3 <br /> License Number e pr pL pH -0 <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> ❑ Curb Cut ❑Water Xt Sewer ❑ Storm ❑ Gas ❑ Sidewalk <br /> ❑ `Street Cut ❑ Phone ❑ Power Li Cable ❑ Culvert ❑ `Street Closure <br /> *Must submit Traffic Control Plan Form <br /> Describe Work: <br /> fi.t/41u6 fide_ s .-4 c,;/ m ire i`i? (..9rl� <br /> PERMIT TYPE <br /> ❑ Curb Cut$50 ❑ Street Cut$50 ❑ Inside Traveled Way$50 ❑ Outside Traveled Way$20 <br /> --i -.) , .-. �� <br /> SPECIAL REQUIREMENTS: Call 1.800.424.5555 two business days before you dig.m -g _ ' •C, <br /> () r1 ri- F-. 1 I Ih <br /> ) .t 'tip Ci <br /> M. j 0 ;--4 -_l C� <br /> '4i <br /> Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right f-- +- . --1:3 T. a <br /> way must be bonded. The applicant and owner must use warning signs, traffic control, and barricad a T. 7 n <br /> necessary to ensure public safety in the work area. The applicant and owner must restore the right-c z is <br /> way to previous condition. The applicant and owner are liable for damage to public and private properly. _ <br /> Ti <br /> L. ••.i <br /> ! roval Signature Da e Applicant Signature Date A _� u I <br />