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. 1 <br /> . . <br /> . . <br /> : . <br /> ..,41...I.4):;.. . <br /> Engineering and Developrrienl Services <br /> PO 6A 547 Anacerles,WA C.4821 <br /> i <br /> riTelephone 360.293 1920 <br /> i'-'ax 360.203 1936 <br /> - ''1:0:016 • . E-mail enpineenncitvotanacortes'aro <br /> 1406:11T-OFMAY PERMIT FRAWCHIS APPLICATION <br /> Submit this application at least fivn days befofe• the work starts Please comptele <br /> both skies ol this form. <br /> . SITE PERMIT ' . <br /> LOCATION: 4S1 .Y0(kskkr: Or NUMBER: 12,0W-20/9 - 00 '25 <br /> FitrANCHISE INVORMATIION CONTACT*R INFQRMAT1ON. <br /> Company NErl16 afTICCA3+-Ccriq ShOkIce-irt" Name '01 ebil-e- INC . i <br /> Mailing Address (to \10,11 'Nue'," t\v) Address 15t_vo Nu) c-6-01 <br /> - CO,State,ZIP -(4) :\lup 1 tAJP, 9.6-6-1-1 City 4,,,,,}...0,e, .. . <br /> Telephone CL-65)5(9 - 315 State tA)pc Zip q NO- <br /> . Fax • Telephone 6,1?.5 —L,o_bli . <br /> • ContagtiNam -I i-CA ti(3 I-I VrIly-Nrie-L. License Number -T-0L,L....)2961W-1 CY1- <br /> PROJECT INFORMATION <br /> Work Inpludes(check all that apply) <br /> El Curb Cut El Water CI Sewer El Storm 0 Gas 0 SidewalK <br /> 0 Steel GUI E]Phone D Power II Cable D CUlveri D 0mm:16111e Traveled Way . . <br /> Describe Work: 5-Voorw\d?\ croryl ---- side rk 000 <br /> bnir-e., 55 -f-+ V---, Iv Ck(005 I n <br /> .. _ <br /> . . <br /> PE rqilt TYPE . <br /> • 0 Curb Cut$50 El Street Cut$50 CI Inside Traveled Way$50 0 Outside Traveled Way$20 <br /> SPECIAL REQUIREMENTS t Call 1,800,424.5556 two business days before you dig. <br /> . . <br /> • <br /> Work within the City Right.4-Way is permitted by approval of the City.Engineer. Ail worA in the right-of- •• <br /> way must be bonded. The applicant-and owner must Lisa warning signs, traffic control;and barricades as <br /> necessary to ensure public safety in the wont area, The applicant and owner must restore the right;of- <br /> way to previouS-cendition. The applicantiand owner are liable for damage to public and private property: <br /> 0//2 <br /> , 1. Apoi.ion Approval Signature- Date Appli n Signature bate' <br /> • . <br /> • <br /> Final Inspection Approval Sightture Date . <br />