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:`4 - PLIC?ATJP FQ,R 4tPUBLIC P
WORKS CQIVTR.U
CTION (ENCROACHMENT
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Ititt"Fbr fthe 'construdtiQn 1"of'.'Publ,iib�,,orlpri%fate "curbs,-tdrive*aysiAkVements,,e's.i.do I W61ksto?pirkingilots;Tiewer..s,.tWatoilmainsjff,-
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in
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SU4divisigp
Improvement
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DATE: 1 19,'ai' e �, ,�,%%_.AuSast 1iiWorImprovement Permit Class
IV
LOCfflO�,9F PONRTRU,�,TION
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Pit 04L,� �%)N �A '10 lei, VfWi�rfy �41�041 Iln' ItIOLIt'v
AVenue 50 r Aljili; t' , -Pivf. — 1N I.,—,
-24 lit
��q.rDescriwiopqfiLy "I I ti:;;
Ore PRO
?URPOSE,OFCONSZie-,,underSround-togethe
TRUCTION Kle,,Sketch (4ttach,con ructioWplowif appropriate)i a:icl
DESCRIPTION OFCONSTRUCTIOW
Y
ached 9 Aal
gi,,nY Y.erAj� ad,..special
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SIZE,OFX
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CAVAT-I'ON-,,IF NEEDED, Pau See attached Sketch.
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M, 1. M, MMMP17
APP,!3QcX1MA,►TE,TJli W.IJENN
G N
APPROXIMATE TI' E'OF COMPLETION ; ifWV164 tou M_Ima,rloo at all loioirl$ `;J ber,11'ec
ESTIMATED CONSTRUCTION
(Including ncZi removal of 11, obstruction, rrkqtqrials, and debris, backfilling, ng ng, com,
ppction and'p n
Jacino, permanent resurfacing and/or replacing impr"ovem q6ts),
In ;gonsideratio ,.of,,thq,,-,agrjaqtingeof/.thistperm.it;ohe applicant hereby agrees to.
lndPm'iiJy,-,defe00,,ap4, spvq,the trity, its authorized agents, officers,' representatives and employees, harmless'from and against any and all
IV, 1"
pimalties, I iabilities'k or loss resulfing from ckr�,
qimtoco�urtidct'i'on)"ai'id�atiting -out ofany accident, loss or dqmage!i6,1jiirsons,6T *,prope
rty
happepint.
pr• occ4rri te-cesultgLon,"(,� up a h� e,�Ti,% r1pt urs to this cation.
`1ffl1;;,0 " 0., W.i's"t —
Uali- 11 flrlql& ft,,t, 9,, P, ig Xqry
4. 'tint
Notify -thqi#.Oryiinistrati..yo,Ayt4prit rqtO.kastoS onty, f Qu r 34.4 wil
Comply with all applicable XijV' brdinancis thi terms and} conditions of thv permlt�and-a(l'applicable rules 13n&rejula
tionsof the City of
-Ja duintlarand to pay fo.r.4.iny,-Idddi'tional).replqcomontthecetsary.as, the);r&sqlt of this work.
Z atm-rwo
n Ont
Name of Applicant , (pl4seprin
-P the:
Tho"pero-u-me'o, f:1, it ly 011 COMC(A,,� " -i, ry tx;rn,,Iameas ot I. W pf*()
n" zioe u -m
V'�PfBuii6eis:Address i - `TiIebh6ne,N'0'..gr„ !" be
Name qtContractde'and'Job'Fdirim6n
C--1.0 324877!
r'-*- o i op lf-%, i - 1 4-
Contrqctor':r Licensq,.No.'icuan6., Oidlfi-arlq,r 1,,461 City Business License No.
Aetna
Applicant's Insu16nceCompanjKJ0',,1.2.1,
Policy.Nvmber*
FEES: Subdivision- ImprovementPermit Class III
ia Public, imprbverribhtit: 3%,w .;,;'Ao I C I PZ Of& P+ 0J 4 a 0Yof Lim 0 4-0 `Z,.! I y' (I tev
f iestim at6d. constructioncosts,*r
Privqtt;e, improvements. 396 of estimated construction costs
-
7. Minor'id- vkwtblli� f P__� d
ImpriDvement,�Peerhit;ZClass.IV.','.$ee,,attache 4cheduIq.4irR�t$,.'.
mam I 'Inq ik M1 I rald
Inspection Fee, n:qvttjdvk$,, 40£a yt PERMITiF1/ALIDAT TION -,y
7
Permit Fi0 (�R! VL WAY 45 09,,-m 'fl.'JA
-L, - aell tht,
IT
PERMIT NQ
Penalty
DATE APPROVED, I' -6E7
Cash Deposit-SurW Bond
•
if req4ir;d
m; F7
1"4, 4�. J14 tim 'i.4 44 V
.N,PA,
TOTAL:
DATE ISSWE
Receipt -.N'-
k4 P,; 10 f 1. �A IE i V 17 1 : Mt, ;oj,47J,
B "Y7
Received by "DateAdniffifstrative
Authority
Recorded, by 7
TELEP.Hp-NE-.46'19)-564 w224.641tioc-1,4 !nusio 4),
F% r%
.04
eto 'a.,
W. . S.0. I may u8 I vowisy ai eu Lui 9 wL:iiy
be replaced by a licensed civil engineer or surveyor at the expense of the permittee. A complete set of notes showing the
ties to these monuments shall be furnished to the City I Engineer prior to the
a rem I oval of any monuments"This I off ice I shall
be notified'6pon completion of "replacement of all survey monuments for proper project clearance.
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