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0.3 19 i 04 000 _ _ :02 <br /> f x` Engineering and Development Services <br /> PO Box 547,Anacortes,WA 98221 <br /> Telephone 360.293.1920 <br /> Fax 360.293.1938 <br /> enoineerinQ citvofanacortes.oro <br /> } <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 <br /> OWNER INFORMATION . CONTRACTOR INFORMATION <br /> Name A,* -.Q,1 Name <br /> Address /.' / — Address sn G), 5}76, <br /> 3 <br /> City 12f q City 1-x)1 ea)-- <br /> i (� Zip �' 2�/ State i/y f7L. Zip cp-�`�.l <br /> State � t /'Va 6 <br /> Telephone Telephone 6/i- 5,/ <br /> License Number <br /> PROJECT INFORMATION <br /> Work Includes (check all that apply) <br /> ❑ Curb Cut ❑Water ❑ Sewer •❑ Storm ❑ Gas ❑ Sidewalk <br /> ❑ Street Cut ❑ Phone ❑ Power ❑ Cable ❑ Culvert <br /> Describe Work: 4.114 r ;�,:� .101 <br /> : <br /> inimminjor <br /> .15 i <br /> 6$119 F '�i&1� �.�t+ <br /> k r �� C"�H ,✓i )k i � F J";:M � , , °: A" ; 3',° �� <br /> �� to <br /> ,.• u.. .:.i .: a.te:.:t"ktit C'rn..: :s;,X'.. n., ..,,:, < 'p% ..f:: .J`S'w%.:? s l4" .'.f:i' .!:!:-:'!:c:'. <br /> .. ... ..., a .C+ ..: ...... •.e:: .a A: :N .f....,.A4. ._... .•:.,,: ..,is":' <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 /> ...,:.............. <br /> 5 r,. <br /> Signature Date�, .. ��� �,V� , � w�r��� N'4 1 ��4s:�`'�; Applicant <br />