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i <br /> CITY OF <br /> DEPARTMENTT OF PUBLIC WORKS 65604 <br />/fOA APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ellme Date /h 7lb� <br /> actor t, <br /> Address J A i Phone <br /> City ZSC4& State Zip 9YS� APPROVED PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work etc <br /> � - / <br /> Owner Contractor Addie llYtit C/ -7By AV4�6&/ Date <br /> ' <br /> `�&5 completion Date z!—C Permit Expiration Date ��^47/- C;' <br /> ! _ <br /> Estimating Starting Date T_ <br /> I (or We)hereby apply for an enroachment permit to carry out the following work &es�raa Ulv�/� ;'Hw .0, uL� <br /> Q6f .[f B <br /> G <br /> 1 <br /> The above named applicant hereby requests permission to PERMIT FEE $ <br /> �i°a��L..eW 5d-e- Ry fw Additional Footage Fee s <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT $ Z �— <br /> Building Permit No <br /> Improvement Plan No <br /> /Supplemental Conditions <br /> /4,✓! Wdll k f0 8e 0r) <br /> 1p..it11 r-tarmfrer L q wi(JQlnD Pl'oU''ecf <br /> 1 iE'Ot5c' Co"'t tc-c.r 6r pry HAI1Pa0k,y <br /> &Cql) x'37-7 03 <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect, and to pay to City Its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the <br /> City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> occuring at the site of, or as a result of, work to be performed under this permit A certificate of insurance shall be submitted to the City <br /> Risk Manager prior to beginning construction <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-600-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUN¢gD UTILITIES <br /> OMITTEE SHALL CALL(209) 937-�24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> PECTION <br /> Read General Provisions on reverse sides p mit be signing - Note require of notifications and Inspections <br /> Signed Phone 3t� <br /> I St Perm;tlee 2nd F 3rd F ance 4th UrdrtyrStreet <br />