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FPOM :CALIFORNIA IAPTEP SERV I i,E FAX N0. :2094G40195 Ju 1. 18 2007 12: 1.4PM P 8 <br /> APPLICATION FOR E9CROAMM PE MIT <br /> Date Oa`VXCX ME ONLY <br /> TO: San 4a tSr JOB # k,7 REF # ----- <br /> Depart**m��e`nt o Puxh+]'��ic Works AP9 qr # <br /> ATE O Mn-MAYS: <br /> (Applicant N=G) STREET s/E <br /> AREA S7VeAV5 QUAD <br /> TYPE <br /> (tailing Addraiso) Po" <br /> (CiCty# Staitt-e1,, Zip�C,od\e) <br /> (Area Code - Telephone Number), <br /> sketch (Detailed plans may be submitted) <br /> The undersigned hereby,applies for peurmissi.on to.excavatei���ct and/or <br /> otherwise-encroach•ou Coxsnty-Highway Right-of-Ray--da•the 13ift.;of . <br /> 0�11J \i• approximate7.yt5Q ' eet mfr N4PCC <br /> Of GU"t kA%T-.Y AVV-- . ' , byperforming the <br /> following work (description of work) : -• <br /> N,'�"T1iL.\.. 1"iLr, C t AL1... <br /> • Clld'Jb ' <br /> Work will commeace ora or°about b"-C�11'(�� for approximately <br /> 164 <br /> days. <br /> S, the undersigned certify that I am the owner of tbLe respective property, or am <br /> qualified to represent the owner and agree to do the work described above is <br /> accordance with the xul i, xegul do 'of San. a0aqudn County and subject to <br /> inspection and approval 09-%I -4C � <br /> sig=tvxe of! Applicamt 'Title Data <br /> +aux�se.as � woo) <br /> ' 1 <br />