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l <br /> • • 65109 i 9 <br /> CITY OF STPUBLIC 6 519 9 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant' lam <br /> (Owner/ ont actor <br /> Address On A) [OdSon (AAY , 57x Kren Phone Zo - - co <br /> Location of Proposed Work, etc. CAST C VAS 1 � IDLS QjoN C APPROVED: PUBLIC WORKS DIRECTOR <br /> n <br /> rAC1FIC Avid U <br /> a Q-tL EFn & � ANLFI ' Foa E R E 6 'F <br /> Contractor Address qVO5 QAGLE�c �{%1eoy STOCI(7-D rV ey Date � 24, <br /> , ' nnnn..�� <br /> Estimated Starting Date eke+o6ct2 Ss ,149S( Completion Date = f 6 $ I r Permit Expiration Date ,� 1� • 29t ( IM8 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : tnS in 11-6q)- Fe <br /> AJ on4tiri o�—IJ CiTyf 091ci � +' C" A V <br /> The above named applicant hereby requests permission to - PERMIT FEE . $ <br /> . . . . . . . . . . . . . . . . . . . . <br /> Additional Footage Fee . . . . . . . . . . . . . <br /> Sewer Tap Deposit . . . . . . . . . . . . . . . . <br /> TOTAL DEPOSIT . . . . . . . . . $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> t%A0 TT a VEv tf, u F� <br /> P{YY tr Eft \nl " PP-fy�C A+J'f� <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 <br /> the 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 <br /> City Risk Manager prior to beginning construction . <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1 -800-S42-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES, <br /> PERMITTEE SHALL CALL (209) 937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION, <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> Signed: " — Phone 2 Cot --b 7�1d 6 <br /> 1st—Permittee 2nd—File 3rd—Finance alh—utility / Street <br />