Application To Perform Work On City Road Right-Of-Way Form - City Of Westport

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_________
Permit No.
CITY OF WESTPORT
PO Box 505
Westport, WA 98595
Phone: 360-268-0835 Fax: 360-268-0921
APPLICATION TO PERFORM WORK ON CITY ROAD RIGHT-OF-WAY
Permit Fee: $50.00
NAME OF APPLICANT: ________________________________________________________ Date: ____________________________________________
The undersigned hereby applies for permission to accomplish work as described on the attached sheet.
Pursuant to RCW 35A.47.030 & 040, Ordinance 579 & Westport Resolution No. 625, dated December 28, 1999
The estimated time required for completion of the above work is ______________________, which the petitioner agrees to prosecute with all diligence and
speed with due regard for the right, interests and conveniences of the public.
Petitioner further agrees to perform the work in strict compliance with the provisions enumerated below and states that he/she has read and will adhere to the
general provisions applicable to permits contained on the reverse side of this form.
ADDRESS: ________________________________________________________________________ PHONE: ____________________________________
SIGNED: _________________________________________________________ BY: _________________________________________________________
TITLE: ___________________________________________________________ JOB NO. ____________________________________________________
PERMIT
Subject to all the terms, conditions and provisions written or printed below or on any part of this form.
PERMISSION IS HEREBY GRANTED the above applicant to:
A bond in the amount of __________________________ is required to insure compliance with the above conditions. Said bond to be kept in full force and
affect for a period of _________ years following completion of work authorized by this permit. The work shall be done under this permit until the parties to
whom it is granted shall have communicated with and received instructions from _________________________________________, City Street
Superintendent.
PHONE: __________________________________. This permit shall be void unless the work herein contemplated shall have been
completed before ____________________________________, 20________.
APPROVED BY: __________________________________ TITLE: ______________________________ DATE: ___________________________________
It is the responsibility of the applicant to notify all utilities and private property owners when such property is liable to injury or damage through the
performance of the above work and the applicant shall make all necessary arrangements relative to the protection of such property and/or utilities.
It is the responsibility of contractors to notify all adjacent property owners of the project prior to commencing any work. It is also the responsibility of the
contractor to notify all affected property owners of any interruption, planned or unplanned, of water services, road closures or power outages.
UTILITY DAMAGE IS COSTLY
CALL BEFORE YOU DIG.
Northwest Utility Notification Center (800-553-4344)
Office Use Only:
Date Permit Fee Paid: ___________________
Receipt No: ____________________________
Performing work on City road right-of-ways without a permit is subject to an additional fee of $250.00 (penalty)

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