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pal 64651 <br /> CITY OF ST <br /> DEPARTMENT OF PUBLIC PUBLIC WORKS <br /> Aa#i APPLICATION FOR ENCRDACHMEaN^rT ON PUBLIC RIGHT-OF-WAY <br /> Asp IicanI 's Name ALL,— �' /� L'�.i fliirn A^j:144L !Dais 11 7 '�._ - <br /> (Owner / Contra to <br /> Address nn • ; Dr- , ( ro -r ^^ � ('Phone ZU5 VE'1 er.0 <br /> Proposed Work, etc. <br /> Location of P (ICJ PA ( i Fl � n APPROVED: . PUBLIC WORKS DIRECTOR <br /> ./9 LC <br /> Owner/ Contractor Address S(A M4 h __ � Z --- ey` Date . <br /> Estimated Starting Date ICompletion Date I Z - / 7 rl Per Expiration Date '' �fict[7-e 1 <br /> I (or We) hereby apply for an p croachment permit to carry out the ollowing work : A1o11,11 r•� Ct�; 5 (4K1S'4 J �i_ '� � Ln <br /> Si « J - <br /> Or- 4 , rr C d h , ( h4 of""ll S+ <br /> E Pf�( I' FQ (��•a Grr , lnd w , Aer ( G ) IcL+: n CO a c � � FIJI <br /> 4t <br /> S <br /> t�f�G( i 1L /S�c i� t�P2i c TSE iit��t0 � t ( 4(?2(r rye' <br /> The above named applicant hereby requests permission to - PERMIT FEE . . . . . . . . . . . . . . . . . . . $_ - t-Z' <br /> Additional Footage Fee . . . . . . . . . . . . . <br /> Sewer Tap Deposit - - - - - - - - - - - - - - - - ___- _ <br /> ' TOTAL DEPOSIT . . . . . . . - . 5 � ZCJ <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <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 . (pZ <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800:642-2444) 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 _ / t/YI'lktirN�fC> G Phone 7' hyj � <br /> 1st— Permittee 2nd—File aFinance 41th—Ulthtyl Sireel <br />