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This page is part of your document - DO NOT DISCARD
RECORDING REQUESTED BY
WHEN RECORDED MAIL TO
03 3459220
RECORDEDIFILEO IN OFFICIAL RECORDS
RECORDER'S OFFICE
LOS ANGELES COUNlY
CAI,-~qNlA
8:04 AM NOV 17 2003
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FOLD HERE
FOLD HERE
TITLE(S) :
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FEE I 0,
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FEE $16 00 I f--------------
OAF $2 , ,
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CODE
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Assessor's Identification Number (AIN) .
To be completed by Examiner OR Title Company in black ink.
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Number of Parcels Shown
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THIS FORM NOT TO BE DUPLICATED
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C~ty ~iyj\tcadia/DdD/Engr.
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240 W Huntmgton Dr
Arcadia, CA 91007
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03
3459220
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CITY OF ARCADIA
DEVELOPMENT SERVICES DEPARTME~T
HOLD HARMLESS AGREEMENT ,r' _u.. - --
Proiect in Public Riqht Of Way :
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This Agreement IS made and entered inlo by and between-the Clly - of Arcaal~ a
municipal organization organized under the laws of the State of California (City), and
0'; "".f E<< '" <?", .6 /: e r ... ~ , (Owner)
and cannot be modified or term nated without wntt approval of lhe Clly
&"0 S. f>Or/~l.V,'~ .Ave
Property Address:
Assessor's Parcel Number:
Re ProJecl Descnptlon
oS ,'ci e w q 11.. s /~O-..., , /;, ~< P/-t.thl12..- s:.~ 0...
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In consideration of and as a condition to Issuance of an off-site or encroachment permit
for the above descnbed obstructlon(s), the undersigned agrees 10 indemnify, defend, and hold
harmless the City of Arcadia, ItS officers, agents, and employees from and against all losses,
claims, demands, payments, SUits, and Judgements of every nature and descnptlon brought or
recoverable against It or them (the City et. al) by the owner, hiS agents or employees, or third
parties ansing out of or In any way attnbulable to the above Job
Owner(s) shall be fully responsible for care and maintenance of subject proJect, agree to
carry continuous insurance In amounts determined by lhe Clly, and shall name the City and ItS
officers, officials, employees, and agents as Additional Insured Owner(s) ackf10wledge and
agree that the permitted encroachment IS subject to removal upon notice from lhe City, If not
removed by owner per City Notice, City may remove and replace same al owner's expense
ThiS documenl shall be binding on all successors In Inlerest to subject property All
parties to thiS agreement have executed thiS Instrument on the date shown below their
signatures,
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Pnnl Name
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Print Name
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Date
/O-/f-03
Date
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c;;;;00CUMENT'MUS'f BE'SIGNEOiB'i'AU,",I!EGAI! OWNERS;ANO:NOTARIZEO,P.RIOR<TO 'CIT.Y?AFlPROV Al:!.;t
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CITY
APPROVED AS TO F"ORM
~y P./~
BY,
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03
3459220
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
7
State of Callfomla
personally appeared
eft,
Namll(s)oISlgoer(s)
~ersonallY known to me
roved to me on the basIs
vidence
of satisfactory
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a RAFAELA MURILLO
COmml!SIOn# 1336519
~ ~ Notary Public - California ~
1 Los Angeles County f
MyCoTTn1 b;:;1l'" Dec27, 2005
____J..________
to be the person(s) whose name(s) Is/are
subscnbed fa the wlthm mstrument and
acknowledged to me that he/she/they executed
the same In his/her/theIr authorIzed
capacltY(les), and that by his/her/their
slgnature(s) on the mstrument the person(s), or
the entIty upon behalf of which the person(s)
acted, executed the Instrument
OPTIONAL
Though 1M tn/anna/ton below IS not reqUIred by law, 1/ may prove valuable to persons relYll1g on the dtxumenl and could prevent
fraudulent removal and reattachment of thiS form to another document
Descriplion of AttaChed Documenl
Title or Type of Document i2~/Jdof~ SQ;t.()le~ Def'fA-(-~ '
Document Datel 15 - / V -() .3 Number of Pages
Slgner(s) Other Than Named Above
Capacily(ies) Claimed by Signer
SIgner's Name
o IndIVIdual
Q.-cOrporate Officer - Title(s)
€"Pllr1ner - 0 limited 0 General
o AttomeY-ln-Fact
o Trustee
D Guardian or Conservator
o Other
Top of lhumb here
Signer Is Representing
019>1>1 N"'llonal Notary ASSOCiation' 9350 De SOlO Ave. PO Box 2402 . Chillsworth CA 91313.2402. w_ nllllonalnoli1ry ol'\l
P,OO No 5907
RllOrder Call Toll-Free 1-800-8766827
CALIFORNIA ALL.pulil~oSE ACKNOw'~EDGr~li~I"'T
r~>''''''''''<'''';'Q&1l:)1;;:~'&.'''''~~''2i8<'.&:5:l'ioQ~=:l'~~='&<>
I State of Calif 01 nli' }
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County of Lo... .I::\~d(>"
On ()('\ "Q~L-4003_beloreme....-Ho.t\o/\t~ ~'-N\{\l\:o.~
Jale I':lImeardTllleofOthcoir(cg,"JlIneOoo NOlllryPublic.")
personally appeared ~\\~ M;~"'It~Q ("
, N(lm~(slolSllP1er(sl
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RECORDER'S MEMO,
POOR RECORD IS DUE TO
QUALITY OF ORIGINAL DOCUMENT
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i _ NoIary NIle. CaIIoINa
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03 3459220
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o personally known to me
;l(l proved to me on the baSIS of satisfactory
evidence
to be the person(\) whose name(t\) ist"'e
subscrrbsd to the within Instrument and
aCKnowledged to me that h\!shettlfFr executea
the ~dl-ne IIi' h~ih&(IU l\iir authorized
capacltY(I~s), and that by h1l>thertt~err
slgnabre(~ on the Instrument the person{\;), or
the entity upon behalf of which the person(\;l
acted, executed the .nstrument
S my hand an1tffl lal seal.
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S,gnatll'Il..AI.:oI...-yPu,:,l,.;
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OPTIONAL
Though the mformatlon be/ow IS not reqUlrod by law, It may prove valuable 10 persons relymg on the document and could pre~ent
fraudulent removal and reattachment of thiS form to another document
Description of Attached Document
.,
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Title or Type 01 Document
Document Date ---o.tS '
\\0\& \-\p..<,W\.\e.-\".
.,,9';>, ,.!,)OO':'
%('€(:'.~I!''''\
Number of Pages -1
,I
Slgner(s) Other Than Named Above
Capacity(ies) Claimed by Signer
Signer's Name'
o Individual
o Corporate Officer - Tille(s)
o Partner - 0 Limited 0 General
o AttorneY'ln.Fact
o Trustee
o GuardIan or Conservator
o Other: ___.
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Signer Is Representing:
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Cl999NatIcnaJNolaryAucdatlQn'9350D9SoIo/lve go eax2~~'Chatswol1h C"'''13132A02'_...n.llonfolnololry'''ll
Prod No 5901
Reo<dotrCanTolI Free 1 <<IC-87tH'.B27