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CITY OF STOCKTON NOV 0 7 1991 <br /> PUBLICDEPARTMENT OF �� r`�Lli� <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC <br /> � No 61559 <br /> Applicants Name Date <br /> Phan .!V/6)q7 2-/1 <br /> Addrassc�2P 1111 —J � 1 APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location oo�ff/proposed Work,etc.4!t? »z<a '2o �45 c'rCPd'- <br /> /L� be a,2" J6C Q.S Sh niJN r'rt <br /> Date <br /> C, ro /Contractor Address B <br /> Estimated Starting Date�-' � <br /> Completion Dote 1,2- / 9 Permit Expiration Date <br /> I for Wel hereby apply for an encroachment permit to carry out the following�ork:—,�7�-T <br /> e c 2 <br /> dl <br /> The above named applicant hereby requests permission to PERMIT FEE ....... _.. $ <br /> Additionol Footage Fee-... ..._ ....._._.. <br /> Sewer Tap Deposit .................................... <br /> TOTAL DEPOSIT ........................ S <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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, <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 not 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 a 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 /> 944-8250signed` –t/ 0/!/✓ Phone <br /> 944.8388 <br /> Ist-permittee 2nd--file 3rd-Finance 4th—Utility/Street <br />