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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS WAO <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0 F'y <br /> / p N° 61095 <br /> Applicant's Name���✓ Ci�'��rR" Pf��• Dote <br /> (Owner/r,�+troctor) <br /> Addres{ds"L-•YGt �_s_/r0 �Q Phone <br /> Location of Proposed Work,etc. !/✓lr J'h iir TG;�t �'— APPROVED: DIRECTOR OF PUBLIC WORKS <br /> c., <br /> Owner/Contractor A By � Dare <br /> Estimated Start' g Dote 5 Z Co tion DQfe' + , ` emit Expiration Dote �— e� <br /> I for We) hereby apply for an encroachment permit to carry out the following work: <�—_ COS <br /> o S <br /> The above named applicant hereby requests permission to PERMIT FEE ................... —" <br /> Additional Footage Fee... .... .... .... <br /> Sewer Top Deposit .................................... <br /> TOTAL DEPOSIT <br /> Building Permit No. r — <br /> Improvement Plan No. <br /> Supplemental Conditions: �- <br /> S <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, <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 requirements. 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 at 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 reverse side of this permit before signing. *Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 <br /> 944.8366 Signed:/� Phan �►'i< 372, Tao <br /> fstRECEIVED SEP 2 2 tc191---Permittee 2nd•�ile 3rd—Finance 4th—Util ity/Street " <br />