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t�41) I <br /> CITY OF STOCK ON R <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF-WAY <br /> M7z <br /> iicant's NameN O r ren tr-� �1 q I�� Date <br /> Owner Contractor l E <br /> Address 3 N. C - S C :Phone 9_i 1qC} <br /> . { t '� <br /> Location of Proposed Work,etc. e�3 LS N .r 'Lt S� S APPROVED: PUBLIC WORKS.OIRIECTOR <br /> Gxrter Coniracto Address <br /> DaleA <br /> Estimated Slatting Dale n Completion Daley Permi!Expiration Dale �. <br /> �?�'s .amu ,rt.,_'� t :w, -_ '• - .- .a' - �� - , <br /> I:,or=We) herebyr apply for an encroachment permit to carry out the follow ing work : <br /> !` U Y- W r L W f T--- <br /> Lt kL ` <br /> The,above named apoicam hereby requests permission to- X <br /> + ', PERMIT FEE..................... 8 _•: _? <br /> � . <br /> �C Additional Footage Fee........ ..... <br /> Sewer Tap Deposit ................ <br /> V09ke C TOTAL DEPOSIT....:.. <br /> x315- �J. it r+1G.t-wrtti cq C !' Building Permit fVn.`` <br /> -y Improvement Plan No.",- <br /> GW Ar1oMT+v.-4Na .: <br /> wtrt Loc4..�,�. Supplemental Conditions: <br /> F <br /> ► +•C 1G .4'J_L",w4o IVI'`7•r r i1 C4 L-4 F'�'Cf`j pexO <br /> S7' <br /> xShow sketch above Or refer rn dmwi„ <br /> ` F0 TAN7'Applicant'hemby,agrees,to,comply with all provisions of this permit as-weft as all applicable City c•rjinances, resolutions, ' <br /> xXOndards and pe.c fications-currently,in effect,and to pay to City its actual cost for removal.and proper.replacement of any item which <br /> saes not mee_aboreufr�ements__Fall�re to comply will be cause for revocation of permit. Applicant agrees la indemnify and hold <br /> :he City harmless against any and all asses,costs,or damages resulting from injury to persons,'death of.person or°damage-to property <br /> occuring at t "Chrork to be performed under this per it.' A certificate of insurance shalt be submitted to the <br /> 'ity Risk Manager prior to beginning construction. <br /> PERMITTI:E SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800- 2-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 24 S PRIO START OF WORK FOR A CONTROL_NU <br /> INSPECTION. MBER'AND TO SCHEDULE <br /> Y - <br /> Read General Provisions on reverse side of is permit 'totre sig a equirement of notifications <br /> Lland <br /> ri�nspe'1ct/ions. <br /> Phone. ' Phw • J <br /> est permittee 2nd—make <br /> rd—Finance 4th—EltintylSireel <br />