HomeMy WebLinkAbout066-470-030t S s E' ss t
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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/pubhcworks/forms.html
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NOTIFY COUNTY 24 HOURS BEFORE WORK IS TO BE DONE
Phone (530) 538-7157 Ext. 2016
Permit Number
0-30 y 2% E
District
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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 except signature must be typed or legibly rinted.
1. Applicant's Name: 1 a. Company Name:
P4 vfa(� /O/'rtL/Ai?D
2. Address:
1,.333 ales( eel 0r. Sam os� �� � 9s�/mss
3. Phone: 4. Assessor's Parcel Number.
a 9a- /o�s
5. Location of Wor to be Dj�e c' /� n l /Y ./
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6. licant' ignpq, 7. Date:
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CONTRACTOR'S INFORMATION
8. Contractor's Name ,_
9. Address
c� iV.�. 4 � rickr CC (G�
10. Phone: /� �• ,_,/� �,
J / Fax: nt 1�' '
12. Contractor's LicenseNumber. !i 13. Certificate of Insurance:
�J Yes No: El
14. Contractor's Signature:
14a. Date Signed:
15. Authorized Agent:
YPE OF WORK TO BE DONE
16. Please Check:
Club: ❑ Gutter: Ef Sidewalk: ❑
17. Driveway (List Type): 5-31
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
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Underground Service Alert .SA. must be notified two working days prior to any excavation. 800-227-2600
20. ❑ All work shall conform to accompanying: Detail ® Plans ❑ Special Conditions P9
21. Date Issued –/18 O3
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/ 22. Expiration Date: -,V v 8 a`7,
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23 Surety: t
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Mike Crump, Director of Public Works
By:
-,Note: If permits are faxed to any number besides (530) 5384356, they can be delayed up to one 4eek.
Page 1 of 2
General Conditions – See Page 2