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ON,0/00 'TUE 11:25 FAX 1 916 861 0130 SECOR-SACRAMENTO �002 <br /> TTY OF STOCKT N <br /> 06A DEPARTMENT OF PUBLIC WORKS 6 513 67 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AD <br /> AAppppllr�nrs Name <br /> (OwrtieItntraMorl <br /> Address D _D Phone <br /> Otrystate _ Zip APPROVED: PUBLIC WORKS DIRECTOR <br /> aT�O�'Sr d <br /> Lvcallan of Proposed Work,10C. _ <br /> Owned Conl(aotorAddresS 88Date 4/y <br /> Estimating Sterling Date mptellon Dale-)k(W�-�.� Parmtt Eoratbn Dale -i�- _ <br /> I(or We)hereby apply for an enroae ent permit to carry out the following wlotk: Q <br /> cr/ <br /> The above named applicant hareby reque6ls permisilan to• PERMIT FEE .S <br /> � <br /> AddMonai Footago Fee...........................S <br /> $9wor Tap Deposit................................. <br /> TOTAL DEPOSIT.............$.`A <br /> Building Permit No. <br /> Improvement Plan No. <br /> i Supplemental Conditions: <br /> Show skmdh above or refer to dmvdng SUbMilted <br /> IMPORTANT: Applicant hsreby agrees to comply with all provisions of this permit as well as all applicable City ordinant.as, resolutions, <br /> standards and specifications currently in e"fect, and to pay to City its actual cost for removal and proper replacement of any Rem which <br /> does not meet Move requirements- Failure to comply will be cause for revocation of permit. Applicant agrees to indemr:ify and hold the <br /> City harmiess against any and all losses, costs, or damages resulting trout Injury to persons, death of person or damage to property i <br /> oaauring at the site of, or as a result of, work to be performed under this pormit. A cenificate of insurance shall be submitted to the City i <br /> Risk Manager prior to beginning construction, <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-000-642-2444) TWO WORKING DAYS BEF0I4F BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUN It.ITIES. <br /> PERMITTEE SHALL CALL(209)937-844t 'FLOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. °6 <br /> Read General Provisions on reverse side of this iit bef re signing - Note requirement of notifications t:d,d inspections. <br /> f S�gned: I 6 <br /> 1st-Pamhiee 2nA-t�a Sr Rnanm 41h LailityN9traet <br /> I <br />