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• 0 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> _0 61699 <br /> Applicant's Nome <br /> 10.ner/Conrroctorl i <br /> AddreaL1�1],(-�I/S,fn <br /> � H � <br /> Ok,eeroLocation ofPropowd Work. ��Phone _//nZ�J-4f�lm <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> arrrr/Contractor Address �+���. �� �y� /S_�� <br /> aOls Lir,dsf � I �Jv1(W/V.r VV) Cm e'1SSZ�. Dote— <br /> Estimated Staining Date �� C pl r p �j, <br /> r T� Permit Expiration Date <br /> t �1 <br /> I for 9(';re by apply for an encroachment permit to carry out the following workf)4, r ne�N <br /> t _ <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE _... ....... _...............__..... . E <br /> Atltl Rionol Footage Fee. . <br /> Sewer top Deposit .................................... <br /> TOTAL DEPOSIT S _— <br /> J�CE <br /> S; _'_E7 ?L4-rJ C�Tr+ � Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or left,to drowma 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 aaolnst 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 cs 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 EngineertInspector <br /> 944-8250 <br /> 944.8366 Sinned. '\\ <br /> etc, <br /> I N­Permmee 2nd File 3rp­Fmonce eM—UNIty/Street <br />