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4;6to RJf3LIC WLr<F,=. r�R a I ,, c <br /> • CITY OF MCKT13N • 6 4 3 2 b <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name corm sng TMy r�o.,.,s.,., D'J d Dam <br /> (Cwner)contmelo') CA 94608 <br /> Adtlress _9D0 Pave 11 sr. 12th Flaor. Fmeryville,, Phone 1.S7.o)t S7-41n6 <br /> rt „ X � APPROVED: PDeLIC WORIG9IXRECf(1R <br /> Location of Proposed WarK em. <br /> D l� DIC <br /> B.g I�aO <br /> n-sit1'_)K <br /> u, lac. A <br /> Owner/Gbntracem Apdnog; _950 It Rd. 11a.rtinez.. CA94553_ 6 1 AL <br /> Esnmatod 9brdng Date Completion Date I Jaya later Pertnn EaOlralton <br /> I (or We) hereby appy p carry Installation of CPP/PIPP boring <br /> I for an encroachment scroll to car out the following work: __ _ <br /> (soil borings frtrm ground surface to SD feet, 2-inch diameter, backfilled with graft) <br /> DF �.•ro%IGTp-i _. �-h:ea fps_ _ . . _ .' <br /> T.8 claw mffte appl'eant hem"'"Wean rxrmieaion k PERMIT FEE............... E <br /> Additional Footage Fee <br /> Scorer Tap Depaa .._.. . . _ . . <br /> TOTAL DEPOSIT ... . 1 -. <br /> Building Permit No. <br /> Improvement Plan No. —.. <br /> Supplemental Conditions' <br /> S.�E A�rrx��A <br /> $nos 8b ,ao,,e m rekr to dmvine suomlmn <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 Clty harmless against any and all losses, costs.or damages resulting from injuryto persons,death of person m 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 al- <br /> PEERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT 11-000412-2444)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPF_CRON. <br /> Read General Prtntisiona on reverse side of this Permit before signing— Note requirement of twtitications/and inspections- <br /> Read <br /> Isis <br /> spD pD�e II Dn tCittt gg CC Si>7nan{tltt. p e: g <br /> *file witCnLhel(:aurt on JenutytY8�n1996- sec LlonriV,'P�egr&PptCazttl Reference to Special Msatert <br /> 1s-Nnnittes <br /> 2nd-FIW Jrtl—Finance dth UAL"ISUCN <br />