HomeMy WebLinkAbout6443 MERLIN DR; ; RW000176; PermitRoy. /15196
CITY OF CARLSBAD - ENGINEERING DEPARTMENT
APPLICATION
RIGHT-OF-WAY PERMIT APPLICATION
408,A , DDRESS mr/rn k
'NEAREST CROSS STREET
ASSOCIATED PROJECT NO .ASSESSO PARCEL NO(S)
DRAWING NO (if applicable)
-BRIEF DESCRIPTION OFWORK P1~
: PROPOSED START DATE - O ESTIMATED COMPLETiON DATE 7 - 5
CONTRACTOR (Permittee)
AME (Pnnt or Type) ?
CONTACT PERSON OU/ S/-i
MAILING ADDRESS 75Jk'€frt&/
PHONE NUMBER
24 HOUR EMERGENCY TELEPHONE
STATE CONTkACTOR'S LICENSE NUMBER:
STATE CONTRACTOR'S LICENSE TYPE: :
/
CITY OF CARLSBAD BUSINESS LICENSE NUMBER
/ By its signature below, permittee agrees to indemnify, hold harmless, and defend the City o Crisbad or
its officers or employees from all daims, 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 orempIoyees This agreement is a condition of the
issuance of a ri -bf-way permit - - - -
SIGNATUE DATE
,The same name must appear on this application the Cash Se m Security Agreement and the request for
refUnda the Pèrrnitter .:-.
R'l-o4-W.y P.".
5•5 - • •- •\ •