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65046 <br /> ` CITY OF STPUBLIC <br /> DEPARTMENT OF PUBLIC WORKS Ii <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAYla <br /> l� <br /> 11 <br /> Apphcan ATr kiii nfQS /0AI //I5.11ttData � <br /> (Owner/ ntractor r (1305) '77 �Il <br /> Address tn(o(c(o Ouu¢r15 Drive Phone Ln,0-530U! <br /> Qr4,)an rlrr� 94588 I APPROVED: PUBLIC,WORKS DIRECTOR <br /> Location of Proposed Work,etc. ,I <br /> 3555 Wgnt H-am i r - /nnarirezr5 Dri vpo� ;i I <br /> wn /Contractor Address qu !t-npir- c/o rnf. mic/�hoa! M,1r vial i g u-'`- Date <br /> 451nTEnt¢rpri5¢ F ¢rr10 , 5 31 <br /> Estimated Starting Date I Completion Date I Permit Expiration Date <br /> i <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> ATC iDmi-ncyno int5 In torn1 r <br /> La -I- z i n' F <br /> iI' ► n• <br /> r <br /> Mil . <br /> F <br /> The above named applicant hereby requests permission to- PERMIT FEE. ............. $ <br /> 5z of-_cam - _I 5I ,ipI an ,l Additional Footage Fee,,.,.,.. i` `r`[ <br /> Sewer Tap Deposit <br /> ll " , <br /> i TOTAL DEPOSIT .... t.. $ i <br /> Ij <br /> I <br /> Building Permit No. <br /> j; Improvement Plan No. i <br /> Supplemental Conditions: ' Ik <br /> !I � `�'•cam: .RM ' ��. .a-t-;C�� <br /> . �c l <br /> Show sketch above or rekr to drawing submitted i <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 <br /> the 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 <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUNDiSERVICE ALERT (1-80042.2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. - i i <br /> j 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 permit before signing — Note requirement of notifications and inspections. <br /> M - � 3 � G8 <br /> Signed' - C__ PM1ane <br /> Dh�P a� ) y(�p0-5 OCA <br /> tst-Permittee 2nd-File dd- ance 4th Utility l Street r <br />