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<br /> i • ITY'' OF."LOD1
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<br /> PUBLIC,WORKS.DEPARTMENT
<br /> �{ 221 W:
<br /> PINE ST 333-6706 r Pt; sd ► !'+ N'?rar,�?Y 1rts1 ttii� ��3 � T r e '"
<br /> CALL BOX 3006 h,
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<br /> "CALIFORNIA ORNIA 95241-1910"I I11 dt - sE�cfti1f E.RM I3�t
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<br /> it Address
<br /> cant's Names Hr s a r r ti f '' xle►
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<br /> cocontractor) tl �' Address . •
<br /> 'jCompletion DateLicense No4t (Sv1 I. f•'r:ler/L''QrttreatorAddress ` ! / �� :�tE°u� rPoneursuant to'the provisions of the Lodi Municipal Code,the'un- rsignedapplies for"permission to excavat®,constri,cf,brfdl0i`Dtnerw1isel�
<br /> 10:;t:,encroach,on City:Street.Right-ol-Way or Easement by performing the.following work,i,,r;tri f}t; i t ft
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<br /> NOTIIFYUSA!(800) 642-2444, 48 OURS PRIOR TOA Y XCAYA ION
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<br /> The work consists of dr+ ry ^r 3:. ritu{. rnTry -fgiy'rh 'X.t, f.
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<br /> i � .,. •.., , .`if t:s'i.°'.7171 s,, , t.r{ rwp ..i f°9 �C;' f.,i', -'? _
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<br /> 71 s; 7i] liJ3:i +ttt" f JLr 17:1!e '�fi] tl�t};Gri 'k
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<br /> Per void if (Space:l=orSketc h):,'
<br /> Work not started within 8 months of permit date.
<br /> ' I - •• .. ..: :. .. . .. .�;,. ;t ?: :'-` .i L.J."ff• ' ' ,
<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 fumed Insured:for'Compre-f
<br /> hensive General and Automobile insurance in the amount of $1,000,000 combined single limit is required.
<br /> The undersigned does hereby agree to indemnify and save the City•of odi freer and harmless from any liability, in accordance with the
<br /> iy provisions of Sec. 12.04.040 of the Lodi Municipal Code. Permittee is specifically,aware,of Sec.12 04,290.thereof relating to,thp relocation or
<br /> removal of said encroachment if future construction requires such relocation. °`''ti'+.3t f'''•i r• •= '•+',<< �. j f ,.s.`. i : t .t
<br /> .-If the work for which this encroachment permit has been issued has not been'coihpleted by 'the City
<br /> .-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
<br /> ''all other costs and fees in accordance with the provisions o Sec 12�4.124'of,the Lodi:Municipal,Code.,i It,
<br /> torr V1 rt1 !•t t.,��;•',r �ri7 ;sti r�oiJvf aur �t [I tri
<br /> y'Dtate:` '4 Signed,
<br /> ..,•r•.�e;n l;t'Y,'.,.�r'77t:i'... ,r ,'I'. ,•.c.7ltl 71 .., ! .;
<br /> �+.,.,
<br /> CRequired
<br /> - 7;This permit is'granted.subject to all,provisions,of.Chapter;,12.04
<br /> plrov,ement - .,of the Lodi Municipal Code, and to all general provisions and
<br /> reCUflty.. applicable special provisions as"shown orrthe reverse sldetkt•t •�
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<br /> ,l 1.brij 'I l'.i °1 fr":J tY'i 't,wp .! Ga 6:1'7`i,r-Y. r �'tr Y`,�•::!«
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<br /> ;'; Permit Approved: CITY OF,LODI ,`7i� '7 !i fri: r c
<br /> Cert. of Insurance , ' Dpj to :ji
<br /> `Referred to `L '=' "f :By,; ` r ��tl• '
<br /> jilan
<br /> JJPub1ic Above,Ground.
<br /> Inspected Date
<br /> Publld"Undergroundt1'`'�`'! '!f>�''s3, ' ° :tris v,
<br /> Completed' Date t.I*'; 't;f�,tiU`Ifd1 ; i' [r i'�;4?f:lf, `e 3r':l ,l:i '��A�;7 ,•i-
<br /> J• '°f . " ❑•It:P.rlvate;,to,bemaintained or,reloc��2aatedbyowner asrequired.
<br /> Reviewed Date thea Permit No _,9.zz;z�Z,. f'
<br /> let•Inspector 2nd-File ' I'd•Permlltee LOP,PAINTING CO. -'
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