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:.� 64448 <br /> © CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> AIAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name r�� ,Vtf-.Date <br /> (Owner/C ntractor) 14(e �(Z <br /> Address 3 �� ti W w� Phone <br /> c,-3ktIj N q- 9 S Zp S' APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> Owner/Contractor Address 2- b q By 07— Date <br /> Estimated Starting Date /- b--1 Q Completion Date Z� " ` Permit Expiration Date ct) - <br /> I (or We) hereby apply for an encroachment p rmit to carry out the following work <br /> r w <br /> Q L h fYW t Ln r" <br /> t.�ae. O 2; <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE..................... $ <br /> Additional Footage Fee............. <br /> Sewer Tap Deposit ................ <br /> �" - TOTAL DEPOSIT......... $ s <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-80A-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <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 hisper it before sign' g — to requ' a nt of notifications and <br /> inspections. <br /> Signed: - —_ /Gy% Phone <br /> 1st—Permittee 2nd—File 3rd—Finance 4th—Utility/Street <br />