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OCT-22-1997 0921 PUBLIC WORKS PERMIT CENTR 209 937 6901 P.02 <br /> 000FA <br /> • CITY OF STPUBLIC • 64613 <br /> A& . DEPARTMENT OF PUBLIC W0RK8 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WAY <br /> 4 bpanfs Narna IawWle. -FOrf Yom' p{y�y,1 <br /> Date 10 <br /> (dwrt° .rrContractar) <br /> Address 9'X[:0- 014 '>R Phona �--�2' <br /> Lopabon of=ad work.etc. APPROVED: PUBLIC WORKS DIRECTOR <br /> OwnerlConbador Addreas >'.ev_nP, <br /> by Data-jQ/2 1.) <br /> Epimatad Slaniny DW 10-n - o}-f cpmyebon veto _{Q�e^ 9'7 <br /> Permit EsPlletion Data _I)n 15-Lm <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> lwaswr Fr.C. ►,a„i R y„� ' ' k pEtA �r 1� �"- <br /> I <br /> TM ab"nerved epD�kenl AerebY r pg•C" - po� 61'"k <br /> armesl5 permiemn p <br /> PERMIT FEE <br /> Addit,onal Footage Fee <br /> " - - - $ewer Tap oeppeit <br /> _— <br /> TOTAL DEPOSIT ... f � 45 <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> Woek. Slaau. BE t2ES12YClL'fl 'l0 <br /> � 8:0o AI.. — 3•.30 A'n Mowlov-r - F4av�Tt <br /> OyX6P GOO- I•-X-,- oOrm;4 rp <br /> Wewr'A� Avg <br /> QQ 1.a+.L(c, tavwee sNau �Y.cwoE h1� <br /> Shw eMch above or rMer b orewinp;�pmnied �� dF � l��Q ��7` . <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 /> .L <br /> .800-2.2444) TWO WORKING DAYS BEFORE BEGINNING <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1 <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 permit before signing —Note requirement of notifications and inspections. <br /> $Ipned i <br /> 1p-Palmlaee pnp11e <br /> ]N-Flrynft elh-UIIIAY/Sryal <br /> TOTAL P.02 <br />