HomeMy WebLinkAbout2840 CARRILLO WAY; ; RW010298; PermitRECEIVED..
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Rev. 11115196
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CITY CARLSBAD - ENGINEERING DEFA MENT
APPLICATION
RIGHT-OF-WAY PERMIT APPLICATION
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JOBADDRESS I4 C4LèA%c.,L
NEAREST CROSS STREET
ASSOCIATED PROJECT NO ASSESSOR PARCEL NO(S) 7Zl z Z
DRAWING NO (if applicable)
BRIEF DESCRIPTION OF WORK C -j --
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PROPOSED START DATE /144 ESTIMATED COMPLETION DATE
. . . •5 .. . CONTRACTCR (Pérrnitte)
NAME(Ptint orType): F t (jr . . .
CONTACT PERSON (sr M -t'-.. H6.J1-rr (ci- u)
MAILING ADDRESS: 441 b&yO r!)4ç c1m4
PHONE NUMBER:*04) i4c-
24 HOUR EMERGENCY TELEPHONE (7 L c
STATE CONTRACTOR'S -LICENSE NUMBER: 77
STATE CONTRACTOR'S LICENSE TYPE: ;. • V
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CITY OF CARLSBAD BUSINESS LICENSE NUMBER 12 h15L
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 a activity or work done pursuant to this permit unless the damage or liability was causedby the sole
a. at e egligenceof.the City, or its officers or employees? This agreement isa condition of the issuance
of ri ht-of-way permit. V ... . . V "_~k
SIdNATURE V DATE -
The same name must appear on this application the Cash Security Agreement and the request for
CITY USE ONLY . .
PERMIT NO: V '• S
ENTEREDINTO COMPUTER BY:
TCP APPROVED BY: . YV/ - DATE: .,
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IINSVURANCE..CHEC K DIBY t DATE
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V G:\L1BRARY\EN6W0RD\D0CSNISF0RMS'FRM00058 (Right-of-Way Permit Application)
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