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EMAIL ADDRESS: City of Lodi Encroachment Permit Public Works Department Application (Construction) Permission is requested to encroach on the City of Lodi's Right of Way as follows: (Complete all items. Use NA, if not applicable. Application is not complete until all required attachments are included.) 1. Permit Address or Street Name 521 !Y- C herAec L 512_L�4) 2. Cross Street(Distance and direction from site) M 0 rr,a_k sy. 4:w)d C'' 3. Applicant it n `� �A,s�r PC) Do- mz C A 95'z 2Gy Xly- � ,Narfi a Address City State Zip Phone No. 4. Contractor G0_t - mz-v C-Cv Name Address ity State Zip 20 j- t- y z; l;'�c` r Ea1} - - Office Phone No. Cellular Phone No. %r License No. -:3t 16�9 Jgg 5. Estimated Start Date Oi/ 24' Z3 Estimated Completion Date, 6. Estimated Cost in City Right-of-Way (Excluding material costs) Q Ca 7. Work Description (Fully describe work within City's Right-of-Way, including any street or lane closures. Attach separate sheet if necessary. Attach complete plans, specifications, calculations, maps, etc., where applicable.): %r►I� it cin w�.ad�"+�e u t m��1-z�;��ny �%�11 ..� -Hi 3�.irts. Orew:>>�:rv�r,sty e,►eer�c(y 75 fzcf cs:�r mcei.-4.,:,141 we"I �j.MI.� in r, , h hc:'J -t& � C Lie c E it�5 Ava E,C11.4z, v5',nj �k �::; jwo ILI ter W ► no i.. er i�r.�'r�CJ( ivwn,a4 o. u.M5 f� I^, cry c 11-� ow,r r Rv oii J- 1rw - rWrv1 M,%,4 umj C,3 8. Additional Information (Check one or more of the following): ❑ Sidewalk Replacement/Installation: Length Lineal feet Sidewalk Width feet(Excluding curb) ❑ Driveway Replacement/Installation(Check one): ❑ Residential Width Lineal feet ❑ Commercial Width _Lineal feet Gutter Type (Check one if applicable): ❑ Square(15"gutter) ❑ Vertical(24"gutter) ❑ Rolled ❑ Driveway ❑ Other,_ ❑ Utility Work L ❑ Excavation ❑ Directional Boring Other U f'i t cr it it el�tC®F1 i tc';` Max. Depth Avg. Depth Avg. Width fc It Length Surface Type�� c '-,"-Conduit: Typ !� '� Diameter 2 r ® Other(Describe): 1 r�s�s. 1'�7cn�� '�Ir�y f.i G�( I/L 1"e- The undersigned agrees to indemnify and save the City of Lodi free and harmless from any liability in accordance with the provisions of Lodi Municipal Code(LMC)Sec. 12.04.040. Permittee is specifically aware of LMC Sec.12.04 290 thereof relating to the relocation or removal of said encroachment if future construction requires such relocation. Permit void if work not started within 6 months of permit date The undersigned agrees and understands that a permit can be denied or a bond required for non-payment of prior or present permit fees,that the work will be done in accordance with City of Lodi rules and regulations subject to inspection and approval. Permit application fees are non-refundable. If the work for which this permit has been issued has not been completed within 6 months of permit date,the City of Lodi shall have the right to complete the work,and to file a Cause of Action to recoup the City's expenses in completing the work and for all other costs and fees in accord ce with the provisions ofthe Lodi Municipal Crode Section 12.04.120. DATE 1( EC& ZV-'- SIGNED - OFFICE USE ONLY PERMIT STATUS: FEE: PERMIT NO. []PENDING ❑FINAL Minimum amount(Balance to be collected at permit issuance) DATE&TIME RECEIVED ❑DENIEDNVITHDRAWN TOTAL FEE: EncroachmentPermitApp.doc 3/12/2004