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4SGTATE OF CALIFORNIA •DEPARTMENT OF �4SPORTATION
<br /> STANDARD ENCROACHMENT PERMIT APPLICATION
<br /> TR-0100 A(REV.11/94) FOR(;ALT HANS USE
<br /> PERMIT NO.
<br /> Permission Is requested to encroach on the State Highway Right of Way as
<br /> follows: (Complete all items:NA It not applicable.) DIST/CO/RTE/PM
<br /> Application Is not complete until all required attachments are Included.
<br /> 1.LOCATION:CITY 2.COUNTY 3.ROUTE SIMPLEX STAMP
<br /> 01'
<br /> 4.POST MILE 5.APPLICATION DATE 16.ADDRESS OR STREET NAME
<br /> 7. CROSS STREET(Distance and directlon from site)
<br /> 8 PORTION-017 RIGHT OF WAYETION DATE 12.EST.
<br /> DATE OF SIMPLEX STAMP
<br /> �Ji cQ2,.Jo.IIL ids-t^ea.�Yt OJF.r s
<br /> 9.WORK TO BE PERFORMED BY, 10. EST.START DATE 11. EST.COMPL T IN STATE RM
<br /> ❑OWN FORCES ONTRACTOR OU; I< ICA& Ocb 1S (-Jq6
<br /> 13.MAX.DEPTH 114.AVG.DEPTH 15.AVG.WI TH 16. LENGTH 17. SURFACE TYPE
<br /> EXCAVATION 52-, NA 6- d` O. Srd�w�.lk
<br /> 18.TYPE 19.DIAMETER ZN 20.VOLTAGE/PRESSURE 121. PRODUCT
<br /> q.)PIPES 4N e- (&-_kdJ1G m NA
<br /> 22.FULLY DESCRIBE WORK WITHIN STATE R/W(additional space on reverse side H needed):Attach complete plans(minimum 5 sets folded 21.6
<br /> centimeter X 28 centimeter(8.5"X 11'))specs,cak:s,maps,etc.,0 applicable.
<br /> Drill cAL gd:awa+e,( So.I bor,._5 Jv a{�rok; sL` lxle�.
<br /> 5M,C`q- avt.d) x,11 2-iny+ d;awVW 6aC&j12 4-W p4c �. ar,d
<br /> LJe tI �J:►t i� JCC -ej a 1alG:.-,p� 2e�«, alaA4 L,)e1i cof c.I+A pi,,4eo,} j:j;, a 4"t-,
<br /> fvc o j^ e j rru..FA-e- rw+ej c ial L-OK e e-v ►v,; cohcvc+-,e_ i.+- L-):%l h c>+ he. ate,
<br /> no6vic-4io.-, +,o pecteskrio.nS. (`40v.4ort t, a ll L-LN W_ iocc.k-e-J evm- in -fie 6ld¢.-.,JAU4-
<br /> ap x;.y,c.�eJu� 15" 5a.�kh O� 4t-e- so��-t,.�erst �vWe- off - �hfi�2eay;a., of so.�,ti,
<br /> aJ s�,ne�{a, mak• (plwv_ s_� ai4vLct-eJ
<br /> YOUR OWN REFERENCE NO. tl C120-070.iA Has any other Caltrans Department reviewed your plans? ❑ YES),NO
<br /> 23.Is any work being done on applicant's property? ❑ YES NO (If"YES',briefly describe in section#22,and attach site and grading
<br /> pians.)
<br /> 24.Is a city,county,or other public agency Involved in the environmental approval?
<br /> ❑ YES (Check documentation type and attach approved copy) EXEMPT ❑N.D. ❑EIR
<br /> ❑ NO (Check a category below in section 24a.,which describes the project)
<br /> 24a.
<br /> ❑ FLAGS,SIGNS,BANNERS, ❑ CONSTRUCTION/MODIFICATION OF ❑ CONSTRUCTION,RECONSTRUCTION,MAINTENANCE,OR
<br /> DECORATIONS,PARADES SIGNALS OR ANY OTHER TRAFFIC RESURFACING OF A DRIVEWAY OR ROAD APPROACH
<br /> AND CELEBRATIONS. CONTROL SYSTEMS AND DEVICES, ❑ ADDITION OR REPLACEMENT OF ROADWAY DEVICES OR
<br /> ❑ DITCH PAVING INCLUDING ADDITION OF NEW MARKINGS(GLARE SCREEN,BARRIER,LIGHTING,STRIPING,
<br /> ❑ FENCE ELEMENTS. MARKERS,ETC.)
<br /> ❑ MAILBOX ❑ PUBLIC UTILITY MODIFICATIONS, 0 MOVIE,TV FILMING AND SURVEY
<br /> ❑ SIDEWALKS/GUTTERS EXTENSIONS,HOOKUPS ❑ EROSION CONTROL
<br /> ❑ REPAIR/MAINTENANCE OF EXISTING HIGHWAYS
<br /> ❑ NONE OF THE ABOVE(if project cannot be described In the above categories,request application Part'B'from the Permit Office)
<br /> 24 b. Does this project cause a substantial change in the significance of a historical resource? 0 YES NO (if'YES',request application Part"B"
<br /> from the Permit Office
<br /> 24 c. s the prolecl Fon an existing highway or street ere the activity involvesremoval o a scenic resource including a stand o treesrorop
<br /> ,a ck outcping or a
<br /> _ historic building? ❑ YES VNO (if-YES' request application Part"B"from the Permit Office)
<br /> The undersigned agrees and understands that a permit can be denied or a bond required for non-payment of prior or present
<br /> permit fees, that the work will be done in accordance with Caltrans rules and regulations subject to inspection and approval,and
<br /> that permit fees may still be due when an application is withdrawn or denied.
<br /> 25.ORGANIZATION OR APPLICANT NAME (`Print or Type) 26.BUSINESS PHONE
<br /> Jro✓. ?rt&JGEs t✓ovv a P�tTL -vhl(rov�w,¢v� 1 q t d� BSt3-L36b
<br /> 27. CHITECT, GIN ER OR PROJECT MANAGER NAME(Print or Ty 28.BUSINESS PHONE
<br /> 29.APPLICANTS ADDRESS(include City and Zip Code) nn
<br /> j1315 ,t�Jnr1K 601 C, c`�1i{tY1 1Ga•1c,Llo 604-'J.,1 611ctS7�d2_
<br /> 30. HO IZED IGNATURE 31.PRINT OR TYPE NAME 32.TITLE 33.DATE
<br /> lx, er. �i/2`f/fib
<br /> EP 9 9
<br />
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