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SEP-16-1997 14:36 PUBLIC NORKS PERMIT CENTR 209 937 8901 P.02 <br /> clry of sracKrDN <br /> 0 64326 <br /> DEPARTMENT OF PUBLIC WORKS <br /> Ar APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAy <br /> Appfitanr's Name Settling I=/_Clea=ing I1eFeadanta: <br /> Add,w 1_901 mor) CA 94608 <br /> Addrmgg 190p bell St. 12th "Fl.cor. Flner�w3il�le, Phone 1510)f S2-4Snn <br /> Location of Proposed work.ew. ru i C, _Itrptlh..� � IaZ=k+G� APPROVED: PUBLIC WORKS DIRECTOR <br /> In-SitV, Inc. <br /> Ow"r/contractor Addreag -950 Aove 7id.. Ma;tinea., CA 44593_ g -0ate— <br /> � <br /> r:5tlmatad Stalling Oete _.l 1 !- _ completion Hate 2 days later _ Permit Explvauon Date AID g <br /> I(or We) hereby apply for an encroachment permit to carry out the following work: Insta11at1On of CPTIPIPI boring _ <br /> (soil borings from ground surface to a0 feet, 2-inch diameter, backfilled with grout) -_rep Cn+.r <br /> rhe ebm named applicant hereby regmsa permission la <br /> PERMIT FEE............... .. S .. <br /> Addeinnal Footmge Fee ... ....... <br /> Se T Tap Deposit ..._.... .... <br /> TOTAL OEpOS1T <br /> Building Permit Na _. _ <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> 5now ah h above w rn r Ib dmxing suM111Re11 <br /> IMPORTANT Applicant hereby agrees to comply with al I 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 ravocatier of permit- Applicant agrees to indemnity and hold <br /> the City harmless against any and all losses,costs,or damages resulting from injuryto persons,death of person or damage tD property <br /> occuring at the site of or as a result of work to be performed under this permit. A cartificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. (i. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800•$42-2444)TWO WORKING DAYS BEFORE BEGINNING <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 /> tNSPECRON. <br /> Read General Provisions on reverse aide of this permit before signiinn"g�— Note <br /> requirement <br /> Off notifications and inspections. <br /> *M99 eB 71C dd .A C &g Si npNpyy C CMCwaY gg Q-e- is yW PnenB V ter, <br /> *files cOiltnathelCauTt onrJflaU 1L'ylY��n1996I 5eCCLonr1V,'PVagraphCcand Referettce CO Special Maeterr, <br /> 1m-NITAI ee 2nd-Flw 3rd-Finance 41h Unhyr�ma <br />