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CIT' CARLSBAD ENGINEERING DEPA ENT
APPLICATION
RIGHT-OF-WAY PERMIT APPLICATION
JOB ADDRESS: L cATYi)KJO RRL
NEAR OS TRET CA ST iA PØ14
ASSOCIA TED PROJEGI'NO.: 3DP ASSESSOR PARCEL NO(S):,_______________
DRAWING NO.. (if applicable): 381 — q (Vgj.'-,
BRIEF DESCRIPTION OF WORK STOrn TIC S
PROPOSED START DATE: Ft-6. 02 ESTIMATED COMPLETION DATE: rtg.
CONTRACTOR (Permittee)
NAME (Print or Type): 8Lta-VV,tj PtL-t).,)f I 10C.
CONTACT PERSON: Ni ArZ.T1 COX
MAILING ADDRESS: lO Ytc SL; Eflifli4Os, 1'.-ô-4
PHONE NUMBER: (i&6 6'34 — / mob do &o. 942LJ
24 HOUR EMERGENCY TELEPHONE: (7c,0) 8OP '-SO / C70) 86 1-10al (.o'b
STATE CONTRACTOR'S LICENSE NUMBER:. lb 2-
STATE CONTRACTOR'S LICENSE TYPE: A
CITY OF CARLSBAD BUSINESS LICENSE NUMBER: /2-0 ?&
By its signature below, permittee agrees to indemnify, hold harmless, and defend the City of Carlsbad or
its officers or employees from all claims, damage or liability to persons or property arising from or caused
by an activity or work done pursUant to this permit unless the damage or liability was caused by the sole
active, negligence of the Ci or its officeyör em S. This agreement is a condition of the issuance
of a right,dJ-way'rmit. /
I . .- '-7' '.._J% \. L.-f ----- J . .'/
/ SIGNATURE
The same name must appear on,,thIs application and the requt for refund
CITY USE ONLY
PERMIT O.: . 7 ./ ' L ' JAt 052004
ENTER 'D INTO COMPUTER. BY: ENGINEERING
TCP A PROVED BYLP/ T.: 3/ DMT
INSURCE CHECKED BY: —EXP. DATE: APPLICATION RECEIVED
Rev. 11115/96 -
/