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CITY OF STOCKTON <br /> L <br /> DEPARTMENT OF PUBLIC WORKS 6b34-1 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AApppplcant's Name �� -a�., yit!Nldr�l.�� Date 3 / 40 Z-- <br /> (Owr►edContractor) <br /> Address 6r7 A�Cx Phone <br /> City C� State Zip7C1' APPROVED PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc <br /> Owner/Contractor Address , ByeDate <br /> ESumaung starting Date —Completion Date Eiration l <br /> Date <br /> I (or We) hereby apply for an enroachment permit to carry out the following work <br /> The above named applicant hereby requests permisslon to PERMIT FEE <br /> Additlonal Footage Fee $ <br /> �� Sewer Tap Deposit <br /> TOTAL DEPOSIT $ i <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Q9 Flo [&we C(a-.ore s acc pe1rrl.'4:;beJ <br /> © Re fl&« 0.11 btb kev,� <br /> fowe.1- c��r:v�.� e�rllliHa� �recs'SS. <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 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 /> occunng 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 /> SHALL CALL(209)937-8491 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> i#ITTEE <br /> CTION <br /> Read General Provisions on reverse side of this perm afore ignmg - Note requirement of notifications and inspections <br /> Sig Phone <br /> fib -o yon <br /> tat Permittee 2nd File 3rd Finance 4th Utility/Street <br />