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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMRNT"ON PUBLIC RIGHT-OF-WAY <br /> /� y- <br /> N6_ 61618 <br /> Applicant's Name��Gt�/ �� Tem Date <br /> (owner/Contractor) -j e'J <br /> Address oe"I OC16I ur �r. (Y.Sr Phon-IN(A1-6 <br /> !1 <br /> Location of Proposed Work,etc.-R& APPROVED: DIRECTOR-OF PUBLIC WORKS <br /> Owner/Contractor Address By Dat <br /> Estimated Starting DateA—a 6-" -- Completion Date 3 lr Eqg Permit Expiration Date <br /> 1 (or We) hereby apply for an encroachment permit to carry out the following Work: 14s� e�✓o ��� <br /> e3 Al Z�6221'�rts� l��o �.3 n 4 6' Ap, <br /> i <br /> The above named applicant hereby requests permission to • PERMIT FEE ............: J <br /> ............................. E <br /> Additional Footage Fee..... .:... ................. <br /> Sewer Top Deposit .................................... <br /> T6tAL DEPOSIT ............/. ......... $ OAU <br /> Building Permit No. ,Z� <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> i <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect; and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requiremehts. Failure to Comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring of the Site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverso aide of this permit before signing.` *Note requirement of notifications and Inspections. <br /> Permit Engineer/inspector <br /> 944-8250 <br /> 944.8366 Signed: Phone <br /> 1st-Permittee 2nd—file 3rd—Finance 4th—Utility/Street <br />