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m� <br /> w <br /> r <br /> CITY Qa,STOCX70N <br /> DEPARTMENT Of Pt;BLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUb"dC CONT-OF-WAY <br /> N'2 61687 <br /> Al - <br /> Add r Pte <br /> APPROVED: DIRECTOR Of PUBLIC WORKS <br /> kocce6on of Prapord war9.ti - <br /> Oester/corwaetor Address <br /> awlenow S1110"lIn4 Tate 7 aZC7�9 Completion Dot hrmlt Expiration Dasa_ `tel <br /> ! for We] hereby apply for an encroachment permit to carry taut the fo;lo ing work: <br /> 600 5r,5� <br /> O <br /> rm above nomw apol;nmf horebY regwstr pwmivan to- PERMIT FU_, ....... ................... f <br /> EaF'r�KG Add-twrmWFootage it" . .. <br /> ... .. - Seust Tap Deposit................................... <br /> TOTAL DEPOSIT ....................... <br /> Building Permit No. <br /> s•npruvement Plan No. <br /> 1 <br /> i Supplemental Conditions: / <br /> f i..y1Ar`>i� �� ar1l��•-. V O <br /> I U _ <br /> mow bloitdt above ar rerW to drorting wbmined <br /> IMPORTANT, Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> standards and specifications currently in effect,and to pay to City its actual cost for removal and proper replace- <br /> rrwnt of arty item which dos not meet above requirements. failure to comply will be cause for revocation of permit. Appli- <br /> tont agrees to indemnify and hold the City harmless against any and all losses, costs, or damoo <br /> es resulting from injury to <br /> persons, death of person or damage to property occurring at the si16 of or as a result of work to be performed under this <br /> perm", Certificate of insurance will be presented by applicant upon request. <br /> Rsitid®ww"I p"slans Ott rivetse side of this permit belors signing. 'Note rssqutnment of notlfiasllane and Inepeotlons. . <br /> T Permit <br /> TItnphttsrllnsp001011' <br /> 4. <br /> '. lsf�erntitte+ Z+fa}-�M irC-•7merKr �Ilti�lJtduy/Stterr . . <br />