Laserfiche WebLink
a� w . � w i <br /> ` CITY of A N <br /> PUBLIC WORKS DE PA TMENT <br /> APPLICATION FOR fhICRQACHME Ohl PUBLIC RIGHT-OF- <br /> WAY �Z��ob <br /> �, �lt1'a�e APPROVED: BY TLI <br /> HE PUBLIC WORKS DIRECTOR �+ <br /> App�canCB NamelJ/l <br /> (OwriaNContractor) -- <br /> P" i E Subject to the General Provlalone and Speoial Camels,and all <br /> Address 3„ _ - I� LA I �_ ne work must 00morm to the projecCs approved Storm wider Poliudw <br /> State Zip Priv 4or+Plan or the City of Swokton Storm Water Palludon y <br /> Prevention Maintenarics Staff ids,whichever is applicable. <br /> Locabon of Proposed work,s 10 S '6 � E�, 144 77 <br /> Owned Contreawr Addreee v0 swOnto <br /> Estimating 3tartfng Dene rU b Completion Date 14-Z.1 it Expiration Date <br /> I (or We) hereby apply for an Fncroaohment Permit to carry out the following work: a { A ' <br /> ar k-InA <br /> M <br /> Thr r hrM6y F090184 Wmissionro- <br /> PERMIT FEE............................S <br /> Additional Footage Fee............$ <br /> Trench t=ee.............................- $ <br /> Sewer Tap Deponit....................$ <br /> TOTAL DEPOSIT.... $ <br /> Building Permit Na. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> QK� tom? AK <br /> ShoW"M sboft of MW to dmwWV tut" 10 <br /> r Ci'c !w l <br /> IMPORTANT: Applicant'hW*by agrees to aompry with sill provWons of this permit, ills app bfe a oidlnances,moludons, <br /> Standards and SpedffGA"M Currwllly in eN&A and to pay to Me City Its actual QdBt fo,removal and proper rsplatament•of any Item which does <br /> rat"loot the above"Iremerits.'Falipm to comply will be cause for revocation of Pon t.Applicant&Woos to Indemnify and hold the Ctly. <br /> haff"ff4 against any and all looses.costs,of damages reauiting from injury to person ,death of person or damage to property occulting at the site <br /> of,or as a reaup of,work to bs perfofmrd under this perrrdt.A certificate of Insurance si iall be subrnittad to the City Risk Manager prior to issue a <br /> of this pemtit ; <br /> PERMITTEE SK4LL CALL(M)07-OW FOR A CONTROL NWSPER NO LES' STH NN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED IP46PECTIONS AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT.BECHN WITHIN 72 HOURS OF THE ISSUANCE.OFA CONTROL.NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SMALL CALL FOR ANEW CONTROL,NU DER.(FOR CAPITAL IMPROVEMENT PRQJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED C TY PROJECT ENGINEER AT(2)9)9374411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE 13EGINNING,OF ANY WORK.) <br /> READ GENERAL PROV'"WAIS ON REVE.M1 SIDE OF M .BItFORE CIMNCiL <br /> tst4'efmrttss(whNO 2nd-Impeoon ipl M rd FTIe(yftllow) 40 Fin (while)l <br /> Z0 3qGd ONIN33NIDNA 77IH1003 E9TTL9E613Z TT=EZ T90Z/91/0T <br />