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i j This permit is Issued pursuant to all provisions of City of Tracy Municipal Code. This permit is granted upon the expresscondition that the permittee shall be responsible for all claims and liabilities arising out of work performed under the permit or arising out of permittee's failure to perform the obligations with respect to,street s maintenance. The permittee shall, and by acceptance of the permit agrees to,'defend,indemnify,save and hold i harmless the city, Its officers and employees,from and against any and all suits, claims or actions brought by any, person for or on account of any bodily injuries, disease or illness or damage to persons and/or property sustained or arisjng iii the construction of the work performed under the permit or in consequence or permittee's j failure to perform the obligations with respect to street maintenance. Permittee agrees to abide by the p ovI Ions of this permit. P MITTEE'S SIGNATURE DATE • is ( Prior to excavation,Contractor must contact the following to have below-ground facilities located(48 hours prior ± �' to work): + UNDERGROUND SERVICE ALERT Toll Free: (800)227-2600 Boyd Service Center (209)831-4420 i Note: You are notified that Section 6500 of the Labor Code requires the issuance of a permit by the Division of Industrial Safety,of the State of California prior to the construction of any trench or excavation which Is five.feef or; deeper and into which a person is required to descent. Excavation in city street areas without an excavation perrnit may be punishable by a fine. Permittee.agrees that they hereby accept complete responsibility for coordination with; reporting.to, and. complyingiwith the direction of,.any and all boards or districts, including but. .0 not limited to, San Joaquinounty Local Health.District and California Regional Water Quality Control Board, or any other regulatory,agency having �i jurisdiction or authority over soil or groundwater contamination such as that currently*found at the site of this: work, including the preservation of the health and safety of persons working near or in any trench or excavation,;,, _ I or on the surface of thR construction project, or any persons passing by or observing, or any persons Ilving:in.the_ vicinity of.the construction project, for any reason whatsoever that may adversely, or otherwise affect the health;.. or safety, now and In the future,of these persons or group of persons. Furthermore,.p6rmittee hereby accepts.complete responsibility.for disposal of any petroleum.affected soils;or ground water, including reporting to and complying with the requirements of any, or all, of the stated,or any'. other, regulatory agencies as discussed above. CITY INSPECTOR'S:COMPLETION REPORT NUMBER- Date of Completion: Duration: j INSPECTOR SIGNATURE: Remarks: Last updated 3/19/2010. Page 2 of 2