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JAN 22 '97 4:07PM CAW <br /> A RESSER MCKEE P.9 <br /> CITY OF 511TICKTON 64199 <br /> OEPARTMENT OF PUBLIC <br /> APPLICATION T <br /> icant's Nafneet �9�cb�7 F° Date 1 <br /> er/Conlradof _ <br /> Address ___.... Phone <br /> APPRIMD: PUBLIC VMKB DIRECTOR <br /> Location of Proposed Work,aft. <br /> Owner/contractor ress i __ — try Rate <br /> im ® ! " Co stion Permk Enpir n D.W <br /> EslI ( ) r apply for an encroachment it to carry out the fall in / <br /> Eb <br /> r l <br /> The above named apoicarit henft requesta Permission to- PERMIT FEE............. .. <br /> AddR l Footage Fee............. <br /> P <br /> Sewer Tap sit ,............... _ <br /> TOTAL DE SIT.........$_ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> C7 <br /> e i p" , <br /> Mum akatch above or relar to drauAng eubmMod <br /> IMPORTANT Applicant hereby agrees to comply with all provisions of this permit as wall 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 Rem which <br /> es not most above requirements. Failure W comply wig be cause for revocation of permit.Applicant agrees In indemnity 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 /> accuring at the site of or as a result of work to be performed under this per 't. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SH, L CONTACT UNDERGROUND SERVICE AL (11-800J- 9.2"4)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATIONF UNDERGROUND TIUTIE . <br /> ! LL(2 09)937-841124 HOURS PRIOR To START OF WORK FOR A CONTROLNUMBER AND TO SCHEDULE <br /> INSPECTKM <br /> Read r I " reverse side of this it before signing requirement of notifications and inspections. <br /> Sgtred: .-- — Ph w y — <br /> tsi— it�a 2nd—File U—Fin a 4th-4ltilitydgtreei <br />