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rte- <br /> . <br /> .x <br /> -M <br /> ' CITE' OF LOCI ENCROACHMENT <br /> PUBLIC WORKS DEPARTMENT <br /> 221 W. PINE ST, 3336706 <br /> CALL BOX 3006 PERMIT <br /> ER I T <br /> LOQI, CALIFORNIA 95241-1910 <br /> Permit AddressQ <br /> Applicant's Name <br /> (Owner/Contraclnry Address .���5�+_ ,5p�yQ <br /> vatl� <br /> Apr.; <br /> Starting Date Completion Date 2—&U4-1—License No. Phone <br /> Owner/Contractor Address Phone <br /> Pursuant to the provisions of the Lodi Municipal Code.the undersigned applies for permission to excavate.construct.and/or otherwise <br /> encroach on City-Streel Righl-of-way or Easement by performing the following work: <br /> T NOTIFY USA (800) 642-2444 48 HOURS PRIOR TO ANY EXC VATION. <br /> The work consists of mAl�� <br /> } l l.� Lllll;ti <br /> DR I Z 1936 <br /> Tr ► bUtT ", n l'� bne <br /> ENI;'ru-+NMEMAL HEALTH <br /> Pi:,tMMSERV,CI=S <br /> r 1 <br /> i t <br /> Permit void if work not started within 6 months of permit date. (Space For Sketch) <br /> ? Dirt,dust,and mud to be controlled by Permittee or City has the right to do the work and bill Owner. <br /> © Certificate of Insurance In the owner's name which names the City of Lodi as an Additional Named Insured for Compre- <br /> hensive General and Automobile insurance in the amount of$1,000,000 combined single limit is required. <br /> g The undersigned does hereby agree to indemnify and save the City of Lodi free and harmless from any liability,in accordance with the <br /> provisions Of Sec.12.04.040 of the Lodi Municipal Code.Permitlee is specifically aware of Sec.12.04.290 thereof relating to the relocation or <br /> removal of said encroachment it future construction requires such relocation. <br /> If the work for which this encroachment permit has been issued has not been completed by <br /> 7 0!Lodi shalt have the right to complete the City <br /> g plete the work,end to file a Cause of Action to recoup the City's expenses in completing the work end for <br /> 4 all other costs and fees in accordance with the provisions of Sec.12.0 1�p of�he Loi untcipal Cod L4 <br /> t �er ata d 1t rc t�,J�1' <br /> Date: Signed: <br /> i Required <br /> Improvement This permit is granted subject to all provisions of Chapter 12,04 _ <br /> ..of.-the-Lodi Municipal-Code;-and-to all genoral provisions.and <br /> --.... - <br /> - — S2CUrlty applicable special provisions as shown on the reverse side. <br /> r: Cert. of insurance Date Permit p ved: IT O L 0 <br /> Referred to c� ✓� 7`/h;P/f lrjs:r irk tri By: <br /> i inspected Date. © Public Above Ground Date <br /> ❑ Public Underground <br /> Compfeted Date_ <br /> Private,to be maintained or rolocaied by owner as required. <br /> Reviewed Date ❑ Other Permit No. <br /> 1177.aoo 7f1.Inrv.elor 2n4i.FRO Mrd-P <br /> rrml!!te L06I PAINTING Co. - <br />