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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61060 <br /> C17G/!/f/�� Date 9 <br /> Apph<MI's Nom. 3n"""_ <br /> {Qr,�r/Conygto(J, r� / <br /> Addretr..//�.6/a'`! ✓!O1/_J✓/T / e<iPhoro�LO ZS�-742G <br /> J � A PROVED: DIRECTOR OF PUBLIC WORKS <br /> Locorlon of Proposed Work,ea. M.93 P/Yn r Y[i <br /> A�. <br /> B Dote..!'Zg_p L <br /> Owrr/Contretlx <br /> Addles, p Q <br /> Estimated stursinp Dau_1�.�=-1-2=—Compleron Date�LParma F.pboHon Dote <br /> 1 (or We) hereby apply for an encroochm nt permit to Corry out th following work: <br /> The obove no.nd opptlwM hemby regvesn permimi to- PERMIT FEE ................... <br /> ..... _. ._..._ f <br /> Additionol Footoae Fee. .. <br /> Sewer Top Deposit ............ _ <br /> i <br /> TOTAL DEPOSIT ........................ f <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> I <br /> Show shah above ar refs,to drawing submined <br /> IMPORTANT: Applicant hereby agrees to comply with oil provisions of this permit as well as oil 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 nor 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 o 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 /> 064-6260 .._ vhene <br /> 944.8366 Signed! -_- <br /> isv--Pormins. 2r4- Ile 3r6-1`monce Ath—utility/Stns, <br />