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% 04, Engineering and Development Services <br /> ' tiup PO Box 547,Anacortes,WA 98221 <br /> Telephone 360.293.1920 <br /> aa�x , *� ei0 Fax 360.293.1938 <br /> °f .:>.; 'o" Tiocci E-mail engineerinq@cityofanacortes.orq <br /> C'Q <br /> RIGHT-OF-WAY PERMIT APPLICATION <br /> Submit this application with payment at least five days before the work starts. Please <br /> complete both sides of this form. (City completes shaded sections.) <br /> SITE PERMIT ��� <br /> LOCATION: 1011 4-1 � 'T I�!!{UIBE�'._: \u <br /> OWNER INFORMATION CONTRACTOR INFORMATION/ <br /> Name `3( vv �?5 1/1 Name D4 <br /> Address ) 0 / 5 v2 f v Address <br /> City City <br /> State Zip ) } State Zip <br /> Telephone 0 0 5 S I Telephone <br /> �t ,> License Number <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> Curb Cut ❑ Water ❑ Sewer El Storm ❑ Gas ❑ Sidewalk <br /> ❑ Street Cut El Phone ❑ Power ❑ Cable ❑ Culvert <br /> t <br /> Describe Work: �(' - � �— i at'ICl/ ` A 1/9 t _;i �(��t <br /> 4 CE Ar <br /> PEMIT TYPE <br /> u b Cut$50 Strat Cut$5t) ❑Ir stile Traveled flay$$0 ❑Outside Traveled Way$20 <br /> S E C I! R E 1fi E S Fl 8.0 42 �555 twc business days before u 1:1 g <br /> W: - s <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 /> CltyA,ptc �sJ�Approvalgha .!� ... Applicant Si nature Date <br />