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11/23/2009 09:21 FAX 209 831 6439 CITY OF TRACY %vow This permit is issued pursuant to ail provisions of City of Tracy Municipal Code. This permit is granted upon the express condition that the permittee shall be responsible for all claims and liabilities arising out of work performed under the permit or arising out of pear ittee's failure to perform the obligations with respect to street maintenance. The permittee shall,and by acceptance of the permit agrees to,defend, indemnify,save and hold harmless the city,its,officers and employees,from and against any and all suits,claims or actions brought by any person for or on account of any bodily injuries,disease or Illness or damage to persons and/or property sustained or arising in the construction of the work performed under the permit or in consequence or permittee's failure to perform the obligations with respect to street maintenance. Permittee agr s bide by the provisions of this permit. fir' t1e.Yrrn r► �r►�n�c.c.'Rca'cc.}�1w�1ri5 11 � � PERMITTEE'S SIGNATURE DATE Prior to excavation,Contractor must contact the following to have below-ground facilities located(48 hours prior to work): UNDERGROUND SERVICE ALERT Toll Fare:(800)227-2600 Boyd Service Center (209)831-4420 Note: You are notified that Section 6500 of the Labor Code requires the issuance of a permit by the Division of Industrial Safety of the State of California prior to the oonstruction of any trench or excavation which is fire feet or deeper and into which a person is required to descent. Excavation in city street areas without an excavation permit may be punishable by a fine. Permittee agrees that they hereby accept oomplete responsibility for coordination with, reporting to,and complying with the direction of,any and all boards or districts, including but not limited to,San Joaquin County Local Health District and California Regional Water Quality Control Board,or any other regulatory agency having jurisdiction or authority over soil or ground water contamination such as that currently found at the site of this work,including the preservation of the health and safety of persons working near or in any trench or excavation or on the surface of the construction project,or any persons passing by or observing,or any persons living in the vicinity of the construction project,for any reason whatsoever that may adversely,or otherwise affect the health or safety,now and in the future, of these persons or group of persons. Furthermore,permittee hereby accepts complete responsibility for disposal of any petroleum affected soils,or ground water.including reporting to and complying with the requirements of any,or all,of the stated,or any other,regulatory agencies as discussed above. CITY INSPECTOR'S COMPLETION REPORT NUMBER- �W Date of Completion: Concrete: Asphalt: Sidewalk: Backfill: Paving: Size of Cut Sq.Ft. Inches Paved By: INSPECTOR SIGN OFF: Last updated 9/1702009 Page 2 of 2