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Jul 17 01 04 20p C1t%-1 of StocktonPW-Permit 12091937-9901 p- 1 <br /> L 1 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC?OA APPLICATION OR ENCROACHMENT CNMEf+1T OIV PUBLIC <br /> 65874 <br /> LIC RIGHT-OP-WAY <br /> tsName Ae,C <br /> caner ontractorl Data /2'G G <br /> Address I�Q Q v 5 0 7 7 <br /> Phone?/7 L 7L' <br /> /, C Zrp gv6,�1-ScTT APPROVED PUBLIC WORKS DIRECTOR <br /> Location of Proposetl��gwcrK etc _3!RZ t f^ i! <br /> r- <br /> zF f7'6 Fi t !'t7Yful r' 1 K 5�.,..�rr7[ <br /> Owned Contractor Address Sam_ t�E.P.'. <br /> DaleEstimating Starting Date 3 c c c Completion Date_-7' j'Q je <br /> 1 <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: /n s i / M"„,T-W <br /> d� <br /> Post-It"'Fax Note 7671 Date ages► <br /> To Frorn t <br /> coJDept Co f <br /> Phone# Phone# <br /> Fax# G-7rFax# r <br /> The above nerned app�ican ere -reques penn¢swn to L <br /> S 'e /97-r (r -k e4 r4,wr-e, PERMIT 3 /A k - <br /> Additional Footage Fee $ <br /> ' W c II cf e. ,3 a t`7 .t a Sewer Tap Deposif <br /> TOTAL_DEFOSIT $ I l <br /> Building Permit No ! <br /> Improvement Plan No t <br /> Supplemental Conditions <br /> � - '' "� fy 1Jca 43112 GI�.,C.crQs 3,2... Uler,ns;ti�� <br /> YcI..T GU -- F <br /> Show sketch above or refer to drawing sutun,tted <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 the <br /> 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 City <br /> Risk Manager pnc�r to beginning cogstructlon <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNOERGROUS US <br /> TILITIE <br />. PERMITTEE SHALL CALL(209) 937=$41-1-24•HOURS PRIOR TQ START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTIONS <br /> Read General Provisions on reverse side of ei efore signing - Note requirement of notifications and inspections <br /> signed �4c: pi , ti . �7 ct,on, j " b -�Q4o <br /> A ist Pormntea d F f <br /> t }'� 3rd Frtenca ath UttnylStreet <br />