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'1 <br /> Cityof Lodi ENCROACHMENT <br /> Public Works Department PERMIT <br /> Permit Address 225 SOUTH CHEROKEE—LANEDate 11/03/2004 <br /> _ _ �_ _ _ -- <br /> Applicant's Name, w --� Address Phone <br />' URS/Mathew Farris Crown Corporate Ctr 2870 Gateway Oaks Dr Cellular (916)679-_2054 <br /> Starting Date Completion Date 01/30/2005 License No <br /> 11/01/2004 Phone <br /> Contractor Address Suite#300 Sacramento CA 95833 Cellular <br />' Pursuant to the provisions of the Lodi Municipal Code the undersigned applies for permission to excavate construct andlor otherwise encroach on City Street Right of way or Easement <br /> by perforrtvng the following <br /> NOTIFY USA(800)227-2600 48 HOURS PRIOR TO ANY EXCAVATION <br /> Work Description <br /> The work consists of off-site soil-boringskiroundwater invests ation as <br /> described In Workplan and correspondence of October 29 2004 Finish <br /> pavement work shall be in compliance with City of Lodi construction__ <br /> specifications and Std Plan No 506 T-trench will not be re uired <br /> PERMIT CONDITIONS ATTACHED ARE A PART OF THIS <br /> ENCROACHMENT PERMIT <br /> NOTIFY CITY INSPECTOR JERRY DEWALT 333-6836 AT START OF <br /> WORK <br /> PROPER REMOVAL OF WORK-RELATED UTILITY MARKINGS IS <br /> REQUIRED CONTACT CITY INSPECTOR FOR REMOVAL INSTRUCTION <br /> (Sketch) <br /> Permit void if work not started within 6 months of permit date ./ Conditions Attached J. Plans Attached <br /> d Licensed Contractor required for this work <br /> V/ Certificate of insurance In the owners name which names the City of Lodi its elected and appointed Boards Commissions Officers <br /> Agents and Employees"as an Additional Named Insured Is required for Comprehensive General Aggregate In the amount of$1 o00 000 per <br /> occurrence and Automobile Liability Insurance to the amount of$1 000 000 combined single limit <br /> Required Improvement Security <br /> This permit is granted subject to all provisions of Chapter 12 04 of the Lodi Municspai Cade <br /> and to all general provisions and applicable speaat provisions as show on the attached <br /> Certification of Insurance Permit ApproyRd CITY OF <br /> Marsh Risk & Ins Services _ <br /> Comp Gen Policy No GL933-3116 Exp 04101/2005 BY _ �—V <br /> Automotive Policy No 826-1679 AOS Exp 04/01/2005 ZbIicbove Ground Date / <br /> Other Policy Exp _ _ _ Public Underground <br /> Referred toJerry Dewalt Date J Private tooemamrarnedorrefocatedhyowner asrequired <br /> Inspected _ Date _ _ _ Permit No 2004-191 <br /> Date Other <br /> Completed _ $82 00 U Paid <br /> 1 is Reviewed Date t=ee <br /> PWD 002(rt- WD <br /> I-J Inspector Copy I i File Copy i 'permittee Copy <br />