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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N ° 62211 <br /> Applicant's Noma CA LrW&ty to 6Io �P _%tl i0fr L Ctllte Date_ uytt�r <br /> (owner /connactod <br /> Address 1) % 1, 1 el s=4 (91 / ,, 1041 cA . 9 )n34 Phone C i — A - 327 <br /> Location of Proposed Work, etc. <br /> SN.a rA) Q ) } _�tk}� D APPROVED: DIRECTOR OF PUBLIC WORKS <br /> )eft-4oI A) LI <br /> Owner /Contractor Address y By Do � <br /> te 7 _ <br /> Estimated Starting Dote J ' 2 7-g3 i Completion Dale —/ ✓ —�� Permit Expiration Dale � / 4 <br /> I (or Wei hereby apply for an encroachment permit to carry out the following work: <br /> The above named applicant hereby requests permission to - PERMIT FEE f <br /> Additional Footage Fee _ <br /> Sewer Top Deposit ... . .. .. .. .. .. . . .... ... . .. . . . . . . . <br /> TOTAL DEPOSIT ... .... . ... ... . ......... T , <br /> Building Permit No . <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> Izoy W1 61 PL/ZGUL l 1 I —gyp <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 /> �{c 944-8250 <br /> 9448366 Signed: Phone <br /> lth-Permittee 2nd—File 3rd—Finance /th—Urflity/Street <br /> Y <br /> I <br />