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i <br /> G41)13f <br /> CITY OF STOCKY N ; <br /> DEPARTMENT OF PUBLI WORKS <br /> APPLICATION FOR ENCROACHMENT O PUBLIC RIGHT-OF-WAY <br /> . J q <br /> ticant's Name N 0 r"nho�9►►1 S Date 313 I <br /> Owner <br /> Address—�g.c-5 : 0. Cq, -�ra' Phone &9 1 <br /> 9_ Gu <br /> 1 `f 1 � � c� i <br /> Location of Proposed Work,etc..a3�s N � :S+ APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner Canlractor Address — +�1��• By _5 Data <br /> Estimated Starting Date -4-20—U Completion Date _5—1` l O Permit Expiration Date <br /> (or We) hereby apply for an encroachment permit to carry outthe following work <br /> ti 2" V C. r L t1 IvLa►-�4 4 W t -�— <br /> szn F' - <br /> D " <br /> The above named applicant hereby recluesis permission to- <br /> l PERMIT FEE......... .. .......... $ <br /> Additional Footage Fee.. ... .. . .. <br /> j Q C\.IOC.rCrRE •�U <br /> Sewer Tap Deposit ...:.... <br /> TOTAL DEPOSIT......... $ — -- <br /> V ogu e C le�� p <br /> X315 lnnnnGI1-rNu�iy Building Permit No. <br /> Improvement Plan No. <br /> GW . <br /> li3 �c�. ,rl�. Supplemental Conditions: <br /> IY'3 /Jcr L�A sK C1•Lu c,Q C— � 1 <br /> pT�12. (�r\,.laa.+_. � A-yLt.cy+�> [cl r[�*r:1.i' (�lrr R.•C�� ��" <br /> Show skelcti abova or refer to drawing suomilled <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 IrorT 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 pe mil. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-j2-2444) 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.NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of is permit Afore sig o egJuirement of notifications and iinnas/yp�ections. <br /> Signed: _ ♦� - y - -- P)rnnn ! J [ <br /> tsl—Permillee 2nd—File Jr, Finance 41h—LfithlylSheel <br />