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4 <br /> Engineering and Development Services O`49 qc� <br /> jt Y Uri PO Box 547,Anacortes,WA 98221 <br /> r. TN:360.293.1920 FAX 360.293.1938 V <br /> EMAIL: engineering@cityofanacortes.org <br /> RIGHT-OF-WAY PERMIT APPLICATION 4 <br /> ci RCW 19.122 Underground Utilities <br /> COB CALL BEFORE YOU DIG -(800)424-5555 '4•per;W Q.. <br /> Applicant shall submit application 5 days prior to start of work and application shall include: <br /> ❑ (1) 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 insured. Minimum$1,000,000 each <br /> occurrence,$2,000,000 general aggregate and$2,000,000 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: ❑ Yes ❑ No <br /> Site Address: City Approved Exemption ❑ Yes ❑ No <br /> `� T-�'� <br /> 0 - EDEN ASSIGNED PERMIT NUMBER: <br /> gave - aoia, - OO4 <br /> Parcel No. <br /> Owner Information (Required) Contractor Information (Required) <br /> Name +., `� Name y _ <br /> Address 0 C 2:-) 4..r Address 7 6 / y <br /> !'fie, r <br /> City AA <br /> _ E:c City * f <br /> Phone Phone <br /> l,,e'- 4 � <br /> / <br /> Email Email �J <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 of Utility Companies is Required) <br /> t11.c — �E u) S tova". � 3.3 y <br /> f91 f6::- 23 4. j LAo. 6 re, 01 ,,,--x..) e— <br /> co <br /> .-r 0 <br /> .,,- n-5' I Z , <br /> City oval ' ature Date 4 c <br /> 0 t:, <br /> C r•.F <br /> By si; at re below Applicant concurs that the Applicant shall defend,indemnify and hold the City, its officials,em- -... , , <br /> plo.ees a',d volunteers harmless from any and all claims,injuries,damages, losses or suits including attorney fees, <br /> . ising o of or in connection with activities or operations performed by the Applicant or on the Applicant's behalf n <br /> out of is-f-I'c- 0 ermit,except for injuries and damages caused by the sole negligence of the City. r•... --._ <br /> / A 0 �, <br /> A ;arsi,41" Date ID <br /> rs <br /> .: <br /> 0 <br /> ( Final Inspection Approval Signature Date * s4" <br /> � / <br />