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CITY <br /> DEPARTMENTT OFF PUBLIC PUBLIC WORKS u J 4 4 b <br /> AiP APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name (�QC)K)X 2f--C6 1, S(.S Date I1- Z-qq <br /> Owner/Contractor) <br /> Address )-11 U Phone 2�fS=S <br /> City / <br /> C SCJn_�, State 104- Zip q S3ZL) APPROVED: PUBLIC WORKS DIRECTOR <br /> Ea <br /> _ <br /> Location of Proposed Work.etc. Ea s 4 <br /> OwneContractor AddressG77UIN z 36S Gcl/CG�17r� S��V �j5/2C/S By Date C <br /> Estimating Starting Date �' Cil Completion Date t0'�'� Permit Expiration Date 'L�+ <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: A&&z 111n / <br /> G / p ,r <br /> r _ <br /> The above named applicant hereby requests permission to- PERMIT FEE. $ <br /> i"iee 522 S��e Tim �T � \ Additional Footage Fee...........................5 <br /> Sewer Tap Deposit................................. <br /> 'J TOTAL DEPOSIT.............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Q, RECEIVED <br /> 1AY 3 6 2000 <br /> ----------- <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold the <br /> City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> occuring at the site of, or as a result of, work to be performed under this permit. A certificate of insurance shall be submitted to the City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this rmit b re signing - Note requirement of notifications can/yd inspections. <br /> Signed- Phone U�a lD 0 n <br /> i st-Pe—ttee 2nd-File 3rd-Finance <br /> 41tn-Uti6ty/Street <br />