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SIt <br /> C Y v Engineering and Development Services <br /> ` PO Box 547,Anacortes,WA 98221 <br /> 4-1111C111 _ Telephone 360.293.1920 <br /> Fax 360.293.1938 <br /> E-mail engineeringAcityofanacortes.orq <br /> 40016 <br /> RIGHT-OF-WAY PERMIT FRANCHISE APPLICATION <br /> Submit this application at least five days before the work starts. Please complete <br /> both sides of this form. (City completes shaded sections.) <br /> SITE <br /> LOCATION: 130816thST • NUMBIER: kpkn.l-- 2 CP)6i l 020 <br /> FRANCHISE INFORMATION CONTRACTOR INFORMATION <br /> Company Name PSE/Potelco Name Potelco <br /> Mailing Address 1660 Park Lane Address 1660 Park Lane <br /> City, State, Zip Burlington Wa 98233 City Burlington <br /> Telephone 425-457-6353 State WA Zip 98233 <br /> Fax 360-766-5504 Telephone 425-457-6353 <br /> Contact Name Susan Sidick License Number POTELI#34404 <br /> PROJECT INFORMATION <br /> Work Includes(check all that apply) <br /> ❑ Curb Cut ❑Water ❑ Sewer ❑ Storm ❑ Gas ❑ Sidewalk <br /> ❑ Street Cut ❑ Phone 17f Power ❑ Cable ❑ Culvert ❑ Outside the Traveled Way <br /> Describe Work: Emergency follow up crew replaced bad pole under job# 101117322 <br /> PERMIT TYPE <br /> ❑ Curb Cut$50 ❑ Street Cut$50 ❑ Inside Traveled Way$50 ❑ Outside Traveled Way$20 <br /> SPECIAL REQUIREMENTS: Call 1.800.424.5555 two business days before you dig. <br /> Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right-of- <br /> way must be bonded. The applicant and owner must use warning signs, traffic control, and barricades as <br /> necessary to ensure public safety in the work area. The applicant and owner must restore the right-of- <br /> way to previous condition. The applicant and owner are liable for damage to public and private property. <br /> 2 it/ 9 Susan Sidick 01/30/2019 <br /> it Applica ion Approval Signature Date Applicant Signature Date <br /> Final Inspection Approval Signature Date <br />