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F <br /> ITY fDEPARD <br /> ENCROACHMENTUBLIC WO1 W. PINE PERMIT <br /> ALL BOX 3ODI, CALIF <br /> Permit Address 5 21 �- Caro k tE ac!iac x�S��a , <br /> Applicant's Name1 11 <br /> (Owner/Contractor) Ua�na & , \ Address ` 14 � OU <br /> Starting Date flet I Completion Date License No. PSI one <br /> T <br /> ! Owner/Contractor Address Phone <br /> Pursuant to the provisions of the Lodi Municipal Code,the undersigned applies for permission to excavate,construct,andior otherwise encroach on <br /> City Street Right-of-Way or Easement by performing the following work: <br /> NOTIFY USA (800) 842.2444 48 OURS PRIOR TO ANY EXCAVATION. <br /> The work consists of vc -s l A4_3 <br /> 1 tilWA <br /> A 1" o <br /> svv�ne t}� ,ur4M n,., 7SA LJ16A I23 <br /> tit 'by\S +OLY a o . wt 6 1Ic <br /> � � � as t-q'd <br /> cd6 � �un � <br /> 17+;1li'tno, L'o. i� 6664'07 C-57 <br /> I <br /> Permit void if work not started within 6 months of permit date. (Space For Sketch) <br /> �( Licensed Contractor required for this work. <br /> ❑ Certificate of insurance in the owner's name which names the City of Lodi as an Additional Named Insured for Com- <br /> i <br /> prehensive General and Automobile insurance in the amount of $1,000,000 combined single limit is required. <br /> The undersigned does hereby agree to indemnity and save the City of Lodi free and harmless from any liability,in accordance with the provisions of Sec. <br /> 12.04.040 of the Lodi Municipal Code.Permittee is specifically aware of Sec.12.04.290 thereof relating to the relocation or removal of said encroachment if <br /> future construction requires such relocation. <br /> It the work for which this encroachment permit has been issued has not been completed by 'Sa, 3V 1995 the City <br /> of Lodi shall have the right to complete the work,and to file0 of me of Action to recoup the City's expenses in completing the work and for all other costs <br /> and fees in accordance with the provisions of Sec.12.04. Lodi Municipal Code. <br /> by <br /> Date 10 sh Signed- <br /> Required <br /> igned Required Improvement Security This permit is granted subject to all provisions of Chapter 12.04 of the Lodi <br /> Municipal Code and to all general provisions and applicable special provi- <br /> sions as shown on the reverse side. <br /> Certificate of Insurance <br /> Comp.Gen. Policy No. Exp. Permit A pr ed: I F LODI <br /> Automotive Policy No. Exp. B 4 <br /> Y� <br /> Referred to f DatebD <br /> ❑ Public Above Ground Date &kbh__� <br /> Inspected Date <br /> ❑ Public Underground <br /> Completed Date ❑ Private, to be maintained or relocated�y owner as required. <br /> Reviewed Date 10 Other Permit No. <br /> white-lnsoector Yellow-File Pink-Penninee <br />