HomeMy WebLinkAbout; ; RW970268; PermitDRAWING NO. (if applicable):
BRIEF DESCRIPTION OF
CITY OF CARLSBAD - ENGINEERING DEPARTMENT
APPLICATION
RIGHT-OF-WAY PERMIT APPLICATION
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NEAREST CROSS STREET:
ASSOCIATED PROJECT NO.: '1)i3 ç ASSESSOR PARCEL NO(S):
PROPOSED START DATE: -i ''( ESTIMATED COMPLETION DATE: Ljj -
CONTRACTOR (Permittee)
NAME (Print or Type): k),1k4/1 (4r1 CiMTi
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CONTACT PERSON: PpT, ILLoCI
MAILING ADDRESS: aoci
PHONE NUMBER:
24 HOUR EMERGENCY TELEPHONE:
STATE CONTRACTOR'S LICENSE NUMBER:
STATE CONTRACTOR'S LICENSE TYPE:
7/1 ct I qcb( a. Own
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CITY OF CARLSBAD BUSINESS LICENSE NUMBER:
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 City or its officers or employees. This agreement is a condition of the issuance
of a right-of-way permit.
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SIGNATURE DATE
The same name must appear on this application, the Cash Security Agreement and the request for
refund as the Permittee.
RECEIVED
OCT 231997
ENf M P
DEPARTMENT
APPLICATION RECEIVED
G:\LIBRARY\ENGWORD\OOCSMISFORMS\FRM00058 (Right-of-Way Permit Application) Rev. 11/15196