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City ofm ( ( Public Works Department <br /> 390 Towne Centre Drive <br /> Lathrop Ca, 95330 <br /> Front Desk (209) 941-7435 <br /> Fax (209) 941-7449 { <br /> :. �4F��E}e ' <br /> Permit No. 20 City Use Only <br /> ENCROACHMENT PERMIT Prepared By: ;.,z <br /> Applicant Information: - <br /> Applicant Name: f Date <br /> 3,330 7.a'+r,'{' a P':7% L� 'J�:i=F 8A-lite, ".M ti^ti: �:!T .. <br /> Mailing address: City:. Zip: <br /> Encroachment Location: <br /> Contractor Information: <br /> Contractor: "` `T Construction Manager. <br /> f.�,+fi' Last St, tt.�0}'°666 2412.=• <br /> Address: Contractor Phone No.: <br /> City: Zip: License No.: (11-57 802334 9 <br /> Bond? O Yes ❑ No <br /> AMOUNT CIIECKBOND# Release of Bond Approved By: <br /> Two (2)24-HOUR CONTACTS - NAME & PHONE NO: <br /> (MANDATORY) <br /> _;rs=e tt.raveri.-.ici stn^ - <br /> PERMISSION IS HEREBY GRANTED TO: <br /> r°xo-roy' 5 2—'a'..d <br /> }>.`•i.t;t2 5� "raT.`._rt-x.k. [°ld..e if''3n vR�-n...:,`�. C.• 2..2 E x_3 s. �N.^r....i'r :i..go a:i3^r Gi fQ% <br /> f.7a pc;e.,_i„• stp., :trtG,... ... '.se-r..,n a: Z.-a t:f a-.r�; V1 Li:'.P L:h Rigs.. ct:. Asa}•. <br /> To do work in the City right of way as shown on attached application you are subject to all the provisions on any part of this form, <br /> and or.attached hereto. <br /> Your attention is directed to the general provisions printed an the track of this form. This permit is to be strictly <br /> adhered to and no work other that specifically mentioned above,is hereby authorized. - <br /> This permit shall be void unless the work hereunder contemplated shall have been completed by: <br /> MJ?tS 20 1.1 <br /> Accepting this permit or starting work hereunder shall constitute acceptance and agreement to all conditions and requirements of <br /> this permit. <br /> Director of Public Works:.. Signature of Applicant: <br /> a/ , <br /> APPLICANTS COPY <br />