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r + JUlf-LJ--JJ IUL L•UJ "I UALiAANO DIU rCAMIIJ CAA L(V. LUJTJYOTJLJL '• STATE OF CALIFORNIA•DEPARTMENT oL_.*aNSPOFITATION A ee Page l STANDARD ENCROACHMERr PERMIT APPLICATION G PART A TR-0100 (REV.11197) 'i7z '- ' �••�•• Perinissian is rNucined to encroach on the State Highway Right of PERMIT NO. Way as follows: (Caaplefe all ileac.:NA ifWl applicable.) g8TJCO/RTFJPM Application is nut LNXtlplete until all required attwh_nunts are included. I.COUNTY ------—---- 2.ROUTE3.POSTMIIE� SIMPLEX STAMP ----- -- 6 ADDRESS of STREET NAME e•CtTW 1117 F105i lT STILRA?10 Toc(/LTOA,f !,GROSS STREET(DA4ulce and dbocaon from ante) 7.PORTON OF RIGI R OF WAY LL-i4 P-1- C7; hlt'UL J`LIL _ __— — A. TO PPLi It U-MSO BY 0.ES7.STMTDATE 10.ESf COFaPLE—f15- DATE OF SIMPLEX S1AMP [_1 OWN f_'OFICESCONTRACTOR 177-1'ZU—_ MTE 11 Z/Z 1 I.MAX.OPTH 2 AVG.DEPTH 3.A G.WIDTH 14.LENGTH is.SUnFACE TYPE 16. FST.COST IN STATE RAM EXCAVATION 17.TYPE 10.DIAMETER 19.VOLYAGE%PP ISO--20.PROg1CT PIPES 21.FULLY DESCRIBE WORK WI If[IN STATE RIW(additional space on reverse side It needed): Attach Complete plans(minimum 5 sets Folded 21.8 centimeter X 28 contlmontor(8.5'X 11'))specs,tales,maps,etc.,It applicable. G+OL }„ JLL�- ZVC�.'•a� Z L4 N,Cr4 '7Cl iL A(�Z1N(> S IN It-Yt (.> rr 7lliwli T'r l7— L t;UL0fI AJx14.2 FIc TtilT- rJ AJ G•v :� T ,'K"ft+-n Ff ��e. .ter, '. N✓,2cN lt.iic„_;�r� tn�✓iS Ti l-H-ii,�! OF /-C IZ i.1FIZ L151 S , TE !s% l (CJ r'IL15t �iC ti.:T LI'It l?R'FL� 'I'! . YOUn OWN REFEnENCE NO.-.__._. __ Has any other Caltrans Department reviewed your Plans? El YES NO 22.Is any work Ming done on applicant's property? (] YES NO (d'YES;bnoffy describe M section$21,am asach site and grading plans.) 43.is a city,county,or other agency Involved In the environmental approval? XVES (Chock docranonfaliun two and alfach aA"voa copy) CATEGORICALLY EXEMPT []N.D. 17]EIR C] NO (Chock elle wrogorybekuv inseetlon23a,wNch describes era Prg0cff 13x. C'j FLAGS.SIGNS,SWIERS._--__--L-I OONSrRUCn0NIMODI(ICATIONOF LJ CONSTRUCMA.-i ECWJSTRI X3T W1anENMICE,OR DECOnAT10N.9,PARAUFS AND SIGNALS OR ANY OTHER IRAFRC CON1f10L F*WFIFACING OF A DRIVEWAY On ROAD APPn0AC14 CeLEORAOR 1_1 DITCHP VV4 SADDITION OF NEW ELEMENTS. (-J S((GA-lInE SCCROn NE'.EENT�r�LIWOTIN t.STRIPING. FENOE n PUBLIC UTILITY MOaFICATIONS. MARIERS,E1C.1 C]MA WI EITENTIONS,HOOKUPS L]MOVIE.N RWNCa []SIDEWALIS I QUI PERS rLr�I EROSIONCONIROL n nEPAIn I iMa1TENANoe OP E%IS moo IocsmAYS LJ sIr1VEY I_J NONE OF n IE AROVF(IfprPJan cv; u to dusuead n aaow ulgla'»a.meiresregpfceliv,Pen a I'm ft Pwme M& .) 2136. Does IMS pNloct CRUWI a sllbSianadl Change In{ho 9gnllicatxa OI a NSIOnICai resource? YES y NO (a•YES;r application Part'13'from tim PermOflican plica) 23 e.U Dia pm)acl on an existing tdgMjny or sr I where the KWily involves lemovoi of a scenic resoirms including a stall of bees,a rock ou{powil or a historic bulldlng7 ( ] YES FNO (If'YES;roglwst application Pan'B'Iran the Pannit Office) The undersigned agrees and understands that a permit can be denied ora bond required for non-payment of prior orpresent permit fees,that the work will be done in accordance with Caltrans rules and reglltadons subject to Inspection and approval,and that permit lees may slitt be due when an application is withdraurfl or dented,and that a denlal maybe appealed In accordance with California Streets and Highways Code, Section 671.5. 2a ORGANIZATION OR APPLICANT NAME(Fria)of Type) ZS WS1NESe m 10NE L Ii N LTL S-Ic' z�t ( u ) 36.WWVIECT.ENGINE:ER On PROUEQTiMxNA(iERNAME(PfilY or or Type) 27 f�1l1SWESSPo IONE KIL I 11-1 `5 I-f-r.. etc-1-- 4e.Q"NESSADDRESS 11rnJudoCity All pCode) � _ ___ _---- lb.AUT I0 S1 NATURE 30 PRIN f OR TYPE NAME _ 31.TITLE 32.DA E -- -/- IIT V- 1T9 -� I,f r-r ' T 1 Z��/•5 yM911 __� '%._I �_ L�\/ _` —r —__.� �.-1_t