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0 63800 <br /> CITY OF STOCKTON <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS !/ �� Cil <br /> q. APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WA � <br /> /r-(UjQ(J D��,p4K.�fil�^7'/G.�D�Q'/ny <br /> Applicant's Name ' leO6P/�' �" r14..5 Date 3/6 6 <br /> Owner/ pact r <br /> Address. X "1690: CA Mane' 973 -76 0/ <br /> �1Q H/d <br /> Location of Proposed Work, eta (J/) lffi t21h7/t a-t�P"_ beh� APPROVED: PUBLIC WORKS DIRECTOR <br /> ! E t l Ce Ji!rsA. <br /> Owner/Contractor Addres 1 10Q ;t/G 7-0r 096 <br /> Estimated Starting Date // I q 4 Completion Date Permit Expiation Date JSP+ 1 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : T / 1- <br /> The aeon named aoPli:ant hereby regoesia per Wm to- PERMIT FEE..................... S <br /> ILS7G/I7YlP ylOtrCltJ4�N/ non/76/7�y w�1�5 <br /> ✓ �./ <br /> Additional Footage Fee............. <br /> vn *e. Cifo>� J7 �p/11�1L'e1S l,yht�F- <br /> Sewer Tap Deposit ................ <br /> otf cAecl Fyure s -7 <br /> L/ MrAL DEPOSIT......... 5 D <br /> a,,e/A4 45)„ //eILS <br /> WJd/ 6e <br /> /OC4� C�1 /{GZPJ76�1 +`� a 6P�P� Building Permit No. <br /> Improvement Plan No. <br /> CoM�ter,e a^`� 61 JOI c 0517.) 401 Supplemental Conditions: <br /> ate Ce•l fe!- Jt-, over�oass. <br /> Shaw sietch above w relar w drawing mt,mined <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 before sig ing — Note requirement of notifications and inspections. <br /> _ .� 973-"77_�f6 <br /> lm—Par W" 2nd le JM—Finance uh—UNINIsbeet <br />