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ti <br /> • CITY OF STOCKTON # 6508-1 <br /> OOOA DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name P&rie)l5 G6_l3'Bp—6&- late 2 - <br /> (Owner/Contractor) `� c, kIU 0"�� <br /> Address W ! cit. I on ID g9' 16 <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. <br /> aLItO�S t� :s L <br /> Owner/Contractor Address By Date l d �' <br /> Estimated Starting Date Completion Date O Permit Expiration Date <br /> I (or We) hereby apply for an encroac ment permit to carry out the following work : L i' - <br /> i <br /> � <br /> a- ti f Ic <br /> 41 <br /> r t crL "— <br /> The <br /> The above named applicant hereby requests permission to- PERMIT FEE. $—__�2-2� ° L� <br /> Additional Footage Fee........... <br /> 4 <br /> Sewer Tap Deposit ................ <br /> t-CLXAJ hl CM 110 14 <br /> J` ^� p l� J TOTAL DEPOSIT......... $ <br /> M IJV 1 Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Or, <br /> tum ' tK <br /> :�)��^i �7�' `fir f'�S•,�l'I��-(7� s°�'4/�p \�"�_` �_�f�c'1A1.1J � <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs, or damages resulting from injury to persons,death of person or damage to property <br /> occuring at the site of or as a result of work to be performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. (o4-Z <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-84.9-2444) TWO WORKING DAYS BEFORE BEGINNG <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. 110'} C)i' f�q — 3;5-6 ,-�`--- <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit fore sig 'ng ote requirement of notifications and inspections. <br /> C 7� Phone ICL�� 9 <br /> Signed. f, J <br /> 1st--Pernnttee 2nd—Fle 3rd-F.r v, -t—utility/strew <br />