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<br /> CITY OF STPUBLIC 64535
<br /> DEPARTMENT OF PUBLIC WORKS ..r
<br /> A94 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY
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<br /> t ApPlicanl's Name _JL^�r��'�t<I�_�C� knv�voH wPq_ �i9 Dale .915 {'� 7� + p.�. I
<br /> (Owner/Contractor) t�(�b'F0 I�.�Q,,N���—w-�`� Ie ZUD
<br /> AddreSs.�flShih.17�`s-r-LI R gSr6 3 Phone 9(L�j� ISO .• :,, y. ,i`e t 1 7 o'.I,:• e� , .E:
<br /> •�`?' So ti t 1. (4-A n't tr S tri t t APPROVED: PUBLIC WORKS DIRECTOR `0
<br /> Locaa!ion of Proposed Wark,atc. {l, `
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<br /> Owner/Contactor Address Sill P%. J 0 R fe__A 1 4 CO y 1kb , gY Date
<br /> Estimated Starting Date Completion Date Permit Expiration Dale OJZ.
<br /> I (or We) hereby apply for an encroachment permit to carry out the following work ' °' ' Fitt 5 I - p a i-1-'t? s of-I a•b o%-
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<br /> The above named applicant hereby requests permission to- r PERMIT FEE •'r' ".' :I $' ” It, 171—,
<br /> I is r:•r 1 + 11 x'-I ' Additional Footage'Fee/t )
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<br /> lr,,., 16i ,i ..,,Sewer Tap_DePosa ........ , I,t I..,I:•
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<br /> TOTAL DEPOSIT... V
<br /> $ 12
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<br /> Building Permit No.
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<br /> a Improvement Plan No. +
<br /> Supplemental Conditions: t ,, t +r
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<br /> ( Show sketch above or rotor to drawing submitted
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<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 propel replacement of any item which' ' y
<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 j
<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.•i " r1 .. c lid ,r Fr
<br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800.6442-4444) TWO WORKING DAYS BEFORE BEGINNING
<br /> WORK FOR LOCATION=937.841
<br /> UTILITIES.
<br /> PERMITTEE SHALL C OURS 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.
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<br /> al—Permittee 2nd—File 3rd—Finance 4th-UlilitvlSVeet t
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