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• <br /> CITYOf OCKTON ib <br /> DEPARTMENT OF UBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT N PUBLIC RIGHT-OF-WAY <br /> 77 N° 63156 <br /> Applicant's NamsDore f� <br /> (Owner/CoMroctw) / 'SIE <br /> p <br /> Addres `ZgZT ,E„ A4!4v+(!e ? Phone ��•5'p�lZ <br /> IS VI M��f 51- APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc.Owner/Contractor Address <br /> Estimated Starting Dote .3 S Completion Date l Permit Expiration Dare J� < 7✓� <br /> I (or Wel hereby apply for an encroachment permit to carry out the following work: <br /> d. 2t,A, L tit �9, e_-2K on <E- <br /> The <br /> The above named applicant hereby requests permission to - PERMIT FEE $ <br /> ...................................... <br /> Additional Foumae Fee. . . ... <br /> Sewer Tap Deposit ......_..._................__... <br /> TOTAL DEPOSIT .......... ............. $ �—�J <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> Permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before si ning. Note requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 �GS�'�12- <br /> 944-8366 <br /> 2- <br /> 944.8366 Signed: Phone <br /> PERMITEE SHALL CALL 937.8411. <br /> Ist—permittee 2nd--file 3rd—Finance 4th—Utihty/Street 24 HOURS PRIOR TO START OF <br /> WORK FOR A CONTRnt Nlwor - <br />