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ENCROACHMENT PERMIT
County of Butte Department of Public Works
7 Count Center Drive Oroville, CA 95965 Phone (530) 538-7157 Ext. 2016 Fax: (530) 5384356
Download Forms: www.buttecounty.net/publicworks/forms.html
NOTIFY COUNTY 24 HOURS BEFORE WORK IS TO BE DONE
Phone (530) 538-7157 Ext. 2016
Permit Number
0 3 1 3 49 7r/
District 1
APPLICATION
I /.WE, the undersigned, hereby apply to the County of Butte for an encroachment permit to do the following work under or over the County roads
and highways, all in accordance with County ordinances and general laws. All information exce t signature must be ed or legibly rinted
1. Applicant's Name: 97,4A/�/�Z
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1 a. Company Name:
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2. Address: NI 0(/
3. Phone:
4. Assessor's Parcel Number:
5. Location of Work to be Done 11 ((►► �^ ,,(
Ac5. S Grid �e �d. lic o S "C how+ MaGecla Ind .
6. Applicant's Signature 7. Date:
CONTRACTOR'S INFORMATION
Contractor's Name
9. Address
10. Phone:
11. Fax:
12 Contractor's License Numbe .
13 ertificate of Insurance: Yes ❑ NO: ❑
14. Contractor's Signature:
14a. Date Signed:
15. Authorized Agent:
TYPE OF WORK TO BE DONE
16. Please Check:
Curb: ❑ Gutter: ❑ Sidewalk: ❑
17. Driveway (List Type):
18. Other:
PERMIT GRANTED
In compliance with the above request, and subject to all terms, conditions (including those on page 2 of this permit form) and special conditions written below,
permission is hereby ted.
19. Conditions /
Underground Service Alert .S.A. must be notified two work:ing days prior to any excavation. 800-227-2600
20. M All work shall conform to accompanying: Detail 1K Plans ❑ Special Conditions C
21. Date Issued U // 03
22. Expiration Date: ! /
o
23 Surety.
cs
Mike Crump, Director of Public Works
By:
** Note: If permits are faxed to any number besides (530) 539 4356, they can be delayed up to one we"ek.
Page 1 of 2
General Conditions — See Page 2