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61L =F5 CFFITF �� _t= a 39-01 P.02 <br /> ��jj� / _ <br /> CITY OF STPUBLIC 6 1, ' 3 <br /> V 4 J <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY t 0 0 ( p 1 <br /> .�;rPlicanl : rJame µ'1_Q 4 e F�.Y 1 r 01t W Py _q I <br /> .9 1 S ! 9 •IOvmer/Osrvac!orl�O'rQaN p _ Date - <br /> UV1 <br /> f :-4dress ah tirp Myrl a. � Pnnne 9{� <br /> 3 t.,—GAS <br /> b8- 31 - <br /> o' �•cpceEC '':aero �� .w 1N}U �-;v h 1 +,., �j iT{'e+ APPROVED: PUBLIC WORKS DIRECTOR <br /> t� IOMI C-ata Ca l-y= 0rKI.iit, <br /> = <br /> p .98 9 <br /> Ownr!corteacrnr Address Sa "� 7o Q Q, h t h Co 4 r{ — a <br /> Estimated 5r I " 'r ' ' - <br /> __ {{ ( <br /> lartia Date ,m L,iinn —L} <br /> 1. _Pe m!E_QvJDvn pale <br /> I (or 'Ve) hareby apply for an encroachment permit to carry out the following work : Ak s - poi -� S of 6 o-i h V { <br /> of ! - I+,e4 ias+ ettr ih c. <br /> -t f�_Sfdtvv4lk fir co!{ e-ction of soil and <br /> �royhgw4ter py fob � kvtrtlartiexfel PVVPOics_ <br /> Yna.iC')r2'LmWd aPo',canl <br /> PERMIT FEE.... <br /> V 1 <br /> A]41!IOY`.31 Fppia(rr R+ _ <br /> —�_ <br /> Sewer lap Gepcert <br /> TOTAL DEPOSIT S _ IZ � <br /> Building Permit No. <br /> V <br /> Improvement Plan. Nc. —_ <br /> • I <br /> Supplemental Conditions. <br /> �1^.i-C�>,: DT .a.•�`.�r _T tip�� ix�ti..wS� <br /> y <br /> 2 s7tr`�Wlti�.�f C�7a.JZ�- 5�.,� C4�-y'2G <br /> iSPcw skC='h aPcve n ... ^nl:v ".11?0 <br /> y IMPORTANT'.Applicant hereby agrees to comply with aft 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 <br /> the City harmless against any and all tosses, Casts. or damages resulting from injuryto persons,death of person or damage to property <br /> occuring at the site of or as a result of work to he performed under this permit. A Certificate of Insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. (14.L <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> y WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> 1. Read General Provisions on reverse side of this permit before signing — Nate requirement of notifications and inspections. <br /> (9163250 <br />