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I $`4158821406 • . SE ICOR SF 002/002 i CITY C) � LC� D� PUf3LfC WORKS DEPARTMENT F- ECROAC 'HMENT - �cl �,a 221 W. PINE ST. 333-C70fi PERMIT CALL BOX 3006 0 LODI, CALIFORNIA 95241-1910 Fpa dress �2q WC-sf L-ockce oet Strt-ef y 's Name (Scof� ontractor) G lrwt� " 6^ ++titir+ /�►^psl r Address 94 Ma>w nn, S1, S.Fa Glate i I') 4 2- D}p5 Completion Date t1 12- .ocemse No. t- +� 72- Phone �I.l� 82.-15�Ipa w+ Ex.olorwfia,.� I ntractor -, AddressZ�8Z3'.�. Mev i eofS24�phons 4s`"19712 the provisions of the Lodl Municipal Code. the undersigned applies fPr p6rR1I9910n to excavate,construct,and/or otherwise encroach an Clly Slraal HldM1f-of Way nr�asamant by performing the following work: NOTIFY USA (800) 642-2444 48 HOURS PRIOR TO ANY EXCAVATION. The work consists of PROPER SIGNING AND BARRICADES 2- I M1f t+l ►pMt G rvuy5r � ,�;`}� REQUIRED PEI)'. CAL TRANS TRAFFIC ' CONTROL'`MANUAL 1990. SIDEWALK " _6611 lac rt W CLOSURE :REQUI RES' PROPER S I GN I N AT SITE. ANp ADVANCE SIGNING FO i � - rnrwLn r� h t.u� 1� -lMr _ A'AVELING PUBLIC'. NOTIFY CITY INSPECTOR (GARY MURDOCK 333-6836); IF WORK' Nor COMPLE ED: t`T AT START OF WORK. INSTALLATION OF WELL AT 5 ' UPDATED .POLICY PRIOR TO 1/19/9 3 '# REQUIRED, t F rlc nf= rttR� N REQUIRED AT AIME OF 1^1lrLL ABANnONMENN Permit void If work not started within 6 months of permit date. (Space For Sketch) ,,2-1icensed Contractor required for this work. Certificate of insurance in the owner's name which names the City of Lodi as an Additional Named Insured forCom- prah8nslve General and Automobile insurance in the amount of $1,000,004 combined single limit is required. { t. The undsr9lgnad duan hereby agree to Indemnify and save the City of Lodi tree and harmiess from any liability,In accordance,with the provisions of sso, 12,04.040 of the Lodl Municipr,i Codd,Permitter)la epectfictslly aware of Soo.12,04.280 theraol relating to the relocation or removal of said encroachment if future construction requires such relocation. If Iha work larrrhlch this encroachment permit has been Issued has not bean completed oy of Lodi shall have tho rlght to complete the work,and the City luso of Atli n to rocoup tho Cily o cxpensos in completing the work and for all other costs and leas In accordance with the provItions of See12.04.120 12.04.120 f the Lodi nicipa Code. . Date_ 12. 7-1 011— Signed CA CO E � FFRaterredto provement Security This permit le granted subject to all prcvielons of lichapter 12.04 of th4,Lodl R Munlckpal Code and to alt g"aral provisions and applicabie special prove- alo6e ae shown on the reverse)tide. f Insurance olicy Na. Exp. Permit roV d: C `FY OF-f-Obi<f �. '411cy Na. `exp �AIiYFtURDt)C _ -,_,�Date�� D F�ublic Above Groundnspeced _ pitta ❑ Public Underground :+ Completed Date " `•` Private, to-be mafnlairted or relocated by'owner ss required- Reviewed - Date � Other Permit No, sreo Sao Whita_Inenw i— vii,_. .eu