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a� . CITY O LODI CENCROACHMENT PUBLIC WORKS DEC I_6�` 221 W. PINE ST. 333-333-6706 PERMIT CALL BOX 3006 LODI, CALIFORNIA 95241-1910 Permit Address / dress �<rGrds��P/lei Applicant's Name/�� 6�`� /ice A (Owner/Contractor)f//for Starting Date Completion Date License No. Phone- Owner/Contractor hone Owner/Contractorw✓� Address Phone Pursuant to the provisions of the Lodi Municipal Code,the undersigned applies for permission to excavate,construct,and/or otherwise encroach on City Street Right-of-Way or Easement by performing the following work: NOTIFY USI\,L600) 642-2444 A HOURS PRIOR TO ANY EXCAVATION. LOyG`Gr �UUq�� The work consists of ,5 ' zoe 4p, tii lo��exsx's � -�W,,4 W47ylll��4& he rrrov ff��Cf / G O ! F J �✓ (Space For Sketch) erml void I wor star ed within 6 mon o per it ❑ Dirt, dust, and mud to be controlled by Permittee or City has the right to do the work and bill Owner. N/ orCertificate of insurance in the owner's name which names th45i y o odi as an Addit--val Named Insured Compre- ensive General and Automobile insurance in the amount 6T1TZM0�00 combined single limit is require The undersigned does hereby agree to indemnify and save the City of Lodi free and harmless from any liability, in accordance with the provisions of Sec. 12.04.040 of the Lodi Municipal Code. Permittee is specifically aware of Sec. 12.04.290 thereo%f relating to the relocation or removal of said encroachment if future construction requires such relocation. "N the work for which this encroachment permit has been issued has not been completed by , the City of Lodi shall have the right to complete the work,and to file a Cause of Action to recoup the City's expenses in completing the work and for all other costs and fees in accordance with the provisions of Sec. 12.04.120 of the Lodi Municipal Code. , Date: �d-I o�1 ` Signed.!/ GXLt/.'d C Required This permit is granted subject to all provisions of Chapter 12.04 Improvement /!1o•, �, -1,,c elle /rest of the Lodi Municipal Code. and to all general provisions and Security zazq&f // b11-11 _ . Ipplicable special provisions as shown on the reverse side: G5A 115(0 /O� f�//i 9O�XP•IPermit Approved: CITY OF. DI Cert. of Insurance ate Referred to By✓, ❑ ,Public Above Ground Date Inspected Date ❑ Public Underground Completed Date Private, to be maintained or relocated by owner as required. Reviewed Date ❑ her Permit No. 1/87-580 tet-Impeclo, 2nd-File 3rd-Permnlee LOOI PRINTING CO.