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OOA 63800 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OFC <br /> � U <br /> Ark <br /> 7q(l �p4K/E� �Dr�(Yrn�/ UUU <br /> Applicant's Name 014: 1606 lI'* C- Date 3/076 <br /> (Owner/ n ract r <br /> Address -7( <br /> 767o PXZ973 <br /> HId0 APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. 6 n /�lID7 ATP de&.61 I <br /> E r 1 1.51-, ^f qq� <br /> Owner/Contractor Address 100 �1 I <br /> /&W B Date_ ZO <br /> Estimated Starting Date 3 //_�/4 —Completion Date rlid I Z Permit Expiration Date JN'U3 t. I6)%, <br /> I (or We) hereby apply for an encroachment permit to carry out the following work: T r r' <br /> O C 7C-r - >c <br /> Sro ea=o • ae <br /> P��tocAw ► t>��n L< 9(uv - D$ <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............ ......... S <br /> �i>sf4/17hPee yroL1K/ra4te� nOn/76/yif4 wt;/LS <br /> ✓ � Additional Footage Fee.... ........ <br /> o� *e C/-� cr14 jr ��ht�t- <br /> Sewer Tap Deposit ................ <br /> War , as sAtow,1 , 4tfrcrlet/ S ure 3 -j <br /> TOTAL DEPOSIT... $ 00 <br /> (MIN -dl If Mid - e y u.lc/M til -a5 ,Ue1L5 <br /> Building Permit No. <br /> wJdl 6e. IOC41&-d 01 /M ze11011 41)C . 6e � <br /> Improvement Plan No. <br /> (Or"f,'ferGt: V-- a,1W L6/JOK(dO5A) 4MP Supplemental Conditions: <br /> Shaw 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(1-800-842-2444) 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 r ,/�b,ef/ogre sig ing — Note requirement of notifications andel inspections. <br /> _�^'v�-' - _. ------ - - plane/S� -�,3--77`T6 <br /> 1st—Permittee 2nd— I6 are—Finance 4th—Ulility/Street <br />