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07;05/01 TNU 12:39 FAX 1 916 861 0450 SECOR-SACRAMENTO <br /> CITY OF S DEPAR N <br /> PUBLIC WORKS DEPARTMENT f•.�+�: I �% <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ppfrcanrs Name `i¢��,� �_ +f J4sr' e _�S-0" APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> t=erfCentractor) ,r! Suhled 10 the General Provisions and Spacial CoWlions,and.all <br /> Address jy �r 'G r 9�8 Phone f work must corHorm W the projecrs approved Storm Water Poitution <br /> City 4 B+�i00d�" State C4 Zip T Prevention Plan or th0 City of S StuWater Pollution <br /> Prevention Maint0n0noe Shah Cul0lo'ulde,Whichever is appllWhla. <br /> Location of Proposed Work,etc. <br /> /ya-7 .� n7� �E Sir• <br /> Owner)Contractor Address By Date <br /> Estimating Staning Date 7-11-61 ComPlet m Dara '-IZ—O on Expiration Date ^'d <br /> (or We)hereby apply for an Encroachment Permit to carry out the following Work? <br /> Yna.no.emm an awry reoe.n.mrm:r�a- <br /> PERMIT FFA_..................___..S 1 <br /> Additional]Poorege Fee__....,.,i <br /> yTrench Fee.",..__.......M_...._-. <br /> Sever Tap Deposit......__._.......S <br /> TOTAL DEPOSIT......_.8 '4 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Keep t.va <br /> show aheKn el,o-w ar rpr¢r ro ataMrd:vYnMM <br /> IMPORTANT. Appllcara herahy agneas to comply with all provisions of this permit,as well mall applicable City ordinances,resdueons. <br /> Standards end SpedfiealiOns currerriy in effect,and to pay to the City its actual coat for removal and proper replacement at any Item which does <br /> not Moet the above requirements.Fallure to comply vAll be cause for rovocatfon of permit.AppricaM agrees ro indemnify and hold the City <br /> harmless against any and sit losses,costs,or damages rtimong from injury in persons,death of person or damag0 to property occurring at the site <br /> of,oras a resue at,work to be performed under this permit.A certificate of Insurance shalt be submitted to the City Risk Manager prior to issuance <br /> of this perm. <br /> PERMITTEE SHALL CALL(206}937-6966 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BU-7 NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OFA CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.9411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS <br /> ii PE IT BE RE SIGNING, <br /> Sipred.[ �4 r/ Phone' <br /> 1S4Perninee(Whltal 2nd-kopartion(11111lr) 3rd He(yellOW) Ath-Rnsnca(whIW <br />