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i <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY i <br /> i <br /> Apppplicant's Name J ��� 4'7€�' � Date J� <br /> (OwnerlC ntractor) <br /> Address Bl7 f--"4 ��- ��� Phone 8G�9��-0 <br /> C� t� zip APPROVED: PUBLIC WORKS DIRECTOR <br /> city State <br /> Location of Proposed Work,etc. <br /> 't/. <br /> r <br /> Owner/Contractor Address 8y Date — <br /> Estimating Starting Date �y 1--i <br /> Completion Date r ennit Expiration Date <br /> I(or We)hereby apply for an enroachment/permit to carry out the following work: <br /> The above named applicant hereby requests permission to- V <br /> PERMIT FEE..........................................$ <br /> Additional Footage Fee...........................$ <br /> � C Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Q I�lo Ea+�� ctasc�r,G� ars. perrl:f�e� <br /> QaNJev �uri�, Irl ll r�o1 �rde-eSS. <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of thisli 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 prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) 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 this permi efore igning - Note requirement of notifications and <br /> � inspections. <br /> Sign Phone: (/t! / �] _O "'7oU <br /> 1st-Permittee 2nd-File 3r -Finance 4th-Utility/Street <br />