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. • . - <br /> • <br /> '•:-4,. I.t:::&, <br /> Engineering ano Development Services <br /> •:',-, PO BA 547 Anacortes,WA 98221 . . <br /> i Telephone 360.293 1920 <br /> pax 360.293 1936 <br /> E-mail enoineenncttvotanacories-3 r c <br /> . RIGHT- WAY-WAY PERMIT FRANCHISE APPLICATION <br /> • .. . <br /> Submit this application at leas. Thin days before. the mirk starts Please complete • <br /> bath sides of this form. . . <br /> . = . • . <br /> . . <br /> • SITE PERMIT <br /> L If CATION: g.:1-13 `.3'3'6 Si-. IILIMEIER: R,OV4-2.0t7 •-0() I? <br /> : 1 <br /> FRANCHIS INFORMATION CM/TRACTOR INFORMATION <br /> . 1 <br /> Company Namb Cory)cci -k•-- (Ai 51yrigef- Name . . ..t.A, ,&:),(--c, kqc <br /> Mailing Address ( vomes_i Av.e Rk jj Address .*AE, Nko 40-11-i .\--. <br /> • City,State,Zip po Lp .k(,) t..),)i t\ 6%39-1 CO <br /> . . <br /> Telephone ° (q?-5)5( - — -315 State uipv Zip c(p)(0- <br /> , <br /> FaX • Telephone <br /> • contpptNanl ---FOiCl.,1% oetnonritr . Li6ense Number .'-uuk.,12,16-1.ctSc-‘ <br /> PROJECT INFORMA,110I4 <br /> Work Includes(check all that apply) <br /> El Curb Cut El Water D Sewer 0 Storm CI Gas 0 Sidewalk <br /> 0 Street Cut 0 Phone El Power • g Coble 0 Culvert El outsldb The Traveled Way . <br /> Describe Work: "DI-Odk\flCI -kortr) .U1 s,Gle c•- <br /> l.13 I kt bry-e c '?)F,-V-; usi ,cia5se9 cx„)._cloy 9-\t5 corl -V.R-, +6 . <br /> Pe• ,- . '--, _ <br /> . _ <br /> PERIVIIT TYPE . . <br /> . 0 Curb Cut$50 0 Street Cut$50 0 Inside Traveled Way$50 D Outside Ira led Way$20 <br /> SPECIAL REQUIREMENTS: G9111.800.424.550 two business days before you dig. <br /> . . <br /> . -. <br /> . . . <br /> • <br /> Work within the City Right,of-Way is permitted by approval of the City Engineer. All work in the right-of- •. <br /> way must be bonded. The applicant and pWhot rnwt use wanting signs,traffic control and-barricades as <br /> necessary to ensure public safety in the walk area. Tha appllapt end.pWnermust restore the right,of- <br /> way to pretilou0oOndltion. The applicant owner are fleas.for dam e to public and privateproperty <br /> , . <br /> • 2 i /c . A "L'k l'Act• , <br /> Applica on 4proval Signature. De e Ap Ip: Signature Date •. , <br /> . . . <br /> . • <br /> Final Inspection Approval$ignetyre Date , <br />