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<br /> 2$ 92 14: 20 ri,r�.r II
<br /> �. 'S'-t15�€8., l6 SEACOR SF
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<br /> CITY OF LODI
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<br /> PUBLIC WORKS DEPARTMENT �P'�� � ' L.
<br /> °Qc! ¢' X21 W. PINE 57. 333.6701E �°`
<br /> CALL BOK 3[06 P E.R i R IT
<br /> LODI, CALIFORNIA 95241.1910'
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<br /> Permrit ,address x-29 west L. ock4_„ f St•� -f- ! �I
<br /> Applicant's Name 6A Coro
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<br /> (CyvnerlContractor) ctr..acr � ,wG 1„ l�.n,o r gID A�
<br /> . -..r.u�_ s tr — :.Address a.., n►►, T' S. F. CA
<br /> 6f
<br /> Starting Date L I'1 �t 2 Completion De#s !J r � - t "
<br /> license Na. ' __ _��'r Phone
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<br /> QuneriCt ntrac 5f,., ►^ti x lore ___ `fS2.s'� phone_ �f 4 Sr 71�
<br /> for . ,., e•-- •• __... 4ddr ss Z$ - MCI,v~ ��f
<br /> Pursuant `-q the provi�lana of the Lcdl lfuniclpe[ Ccdw, the undarsigned applies lfor permlaslar to excavate,CSn'gtn"t e?1d14i o`therwlea errctoach on
<br /> :icy Sheet Right-of-Way or Fassmeftt by performing the 181rowing won k:
<br /> NOTIFY USA (Boa) 642.2444 48 HOURS PRIOR TO ANY EXCAVATION.
<br /> The work consists of 1
<br /> PROPERiSIGNIIG AND BARRICADES
<br /> REQUIRE€} PER CAL TRAINS T'RAF'FIC
<br /> CONTROL MANUAL 1990. SIDEWALK
<br /> � �I c t �L ., taed r �e sl w� a _ CLOSURE REQW-RES PROPER SICNIN
<br /> €J -- AT SITt ANDI ADVANCE SIGNING FO
<br /> 7 IV :_._w�rw_ [ r{ I r� t � �^r- + TleAV EL I ISG P613L I C, i
<br /> NOTIFY CITY INSPECTOR (GARY MUKDOCK 333-6836
<br /> ----- - M � I F WORK NOT COIaPLE ER
<br /> _ ATSTART Vf WORK. INSTALLATION OF WELL AT S ; LIPDATEO POLICY PRIOR TO is/?9,19 3
<br /> _. — REQUIRED. d .I
<br /> WATT REQUIRED AT `TIMET OF WELL ABAN'DONMEN
<br /> Perrn,it void ii work not started with n 6 months of perrt'tit date- (Space For Sketch)
<br /> "Licensed Contractor required for this work,
<br /> Certiftcate of insurance in the owner's name which names th6 City of Lodi as an Additional Named Insured for Com•
<br /> prY14 anslvt^ Generai and Automobile insurance in the arnouni of $1,000,000 combined: Ingle limit'is required.:
<br /> The under,-igned does hereby agree to Indemnify and save the Glty of Lodi free and!harmresa from any 118Ai1ity,In aCCord6}rtta With tft6 pts3viSlArtS cis Sac.
<br /> 1 .0e.040 of ihu-Lodi Municipa`"oe,Permittee is 8pecit:tally avearc of Soc,12.O�.ZSq Iharaot ro3a;lr,g to the relocation or rerrmval of said encroacnmert if
<br /> {i!tUre Gongtrurf,on requires such relocation, ,i
<br /> If the Wu:y'or ;',ch tars er.croachmer.•t permit has been issued has not peen compieted 5, tt{9 City
<br /> of Lc-ai t4all Lave Tho r,9rt to complete tye worl�,a'tid, �uxa GI Acti n to racoup tho Cliy's ozponsoo m completing the work and fcr all other'costs
<br /> and fees in accbrdarco w?ih the provirl&ns df sa - t2.�4.t24 f the tQdl unicipa�Cada. i1
<br /> Date_}ZI �`,... _— $igrted J&
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<br /> 1 �i
<br /> rRaprovement Security Th}slparwit la granted subject to all provlslors of Chapter 12.0,4 of the LodiMunlcltsal Cade end to sll general prevlslanarand applirabla spealill provl-
<br /> slan's ae shuwr,on the reverse side,
<br /> of insuranceRoliQy No. , Exp. Permit roved: .TY OF LODI
<br /> Automotive Policy No. � Bxp._---�w ;.,�r
<br /> ateInPcferred to GLV ret) C Date—_ '!public Above Ground ` Date-
<br /> Inspected
<br /> spected Date C1 Public Underground
<br /> Completed bate13
<br /> PrlYstt3, fc D$mµ Rlalree or raroca{act by owner g5 rbQulPBd.
<br /> 7 �
<br /> Revlewed Date— ' Other Permit No, I� ✓G/ u
<br /> S?90 500 Whoildriypoctm Ycllpw.Fhlo Ink-777tee i1 AhfirE,Pso�Pr'litiny� �
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