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• <br /> • <br /> r Engineering and Development Services 4c9 -4 <br /> Q PO Box 547,Anacortes,WA 93221 �' <br /> TN:330253.1620 FAX 350.283.123E `t' <br /> EMAIL' engineering@cityofanacortes.org <br /> `� - cn. RIGHT-OF-WAY PERMIT APPLICATION a F" z <br /> �i- RCW 19.122 Underground Utilities • <br /> C p-- CALL BEFORE YOU DIG -(BOO) 424-5555 4 —•—�P P • <br /> Applicant shall submit application 5 days prior to start of Work and application shall include: <br /> ❑ (Si) 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 insurer_ Minimum$1,000,000 each <br /> occurrence,$2,000,000 general aggregate and$2,000,0D0 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 City. 0 Yes ❑ No • <br /> Site iAddress: City Approved Exemption ❑ Yes ❑ No <br /> • i-a f 2 0 PGA. -. EDEN ASSIGNED-PERMIT NUMBER: <br /> Parcel No. VOtel - p <br /> • <br /> • <br /> Owner Information (RegUired) Contractor information (Required) <br /> Name Name _ <br /> S.y e v ri 4 / c,, ka. • <br /> Address Address <br /> I ill 11 .g0 — S - i`1/b Lit SEA/= <br /> City //�� / �, • <br /> / City mink -6,' f�J AfAlt- -c/f <br /> Phone Phone <br /> • <br /> 310 it ‘et1•_ i3 .3 <br /> Email -Email <br /> Address Address <br /> Work Includes (check all that apply) • <br /> ❑ Curb Cut ❑ Water ❑ Sewer ❑ Storm ❑ Street Cut ❑ Sidewalk ❑ •Phone ❑ Other <br /> • Describe Work to be Performed: (Notification e of-Utility Companies�+ is Required) • <br /> p let c side_ fj ewwwf lr C L/Cr y. e m ("o t b ill <br /> +' ., 'r- <br /> •t <br /> G _ G ,1—, 11 ry <br /> r¢. .* C 7 <br /> . C' t Pero i tura Date ,,. ;•r Jotr, <br /> • <br /> nature below Applicant concurs that the �- <br /> BY pp' Applicant shall defend,indemnify and hold the City,its officials,em- 1, r r <br /> pi'. -es and volunteers harmless from any and all claims,injuries,damages,losses or suits including attorney fees, ; • ' C' 4:1 , <br /> -, -ng out of or in connection with activities or operations performed by the Applicant or on the Applicants behalf 1 F, = <br /> am •of issuance of this Permit,exceptfor injuries and damages caused by the sole negligence of the City. _ =� <br /> , '' <br /> dr ,j r <br /> 2. a C i , <br /> 'r 4, <br /> L nt Signature Date r <br /> •4:1 •.�, <br /> • <br /> Final inspection Approval Signature Date . .; ' <br /> °a I•_i' <br /> I C7., <br />