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r3 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR El--ROACHMENT ON PUBLIC RIGHT-OF-WAY Y J 7 3 <br /> Iv_ <br /> Z 1� — <br /> Phons — p ROVED: DIRECTOR OF PUBLIC WORKS <br /> 4dre% <br /> cation of Pro Pared Wotk,etc. i I <br /> . �•nmer/Contractor pySraa Zc}O t ,� . <br /> Completion Date <br /> I- _ _Permit Expiration <br /> l •-• <br /> caelmalsd Starting DatO <br /> I for an encroachment ppermit to carry out the following work: <br /> a <br /> "'jor We) hereby apply <br /> If1Si <br /> = The ab"s named applicant hamby requests permisrion to <br /> PERMIT FEE ......... <br /> Add,tional FoW19e Fee.... .....-.. . <br /> .. Sewer TaP pepatil ................... <br /> TOTAL DEPOSIT -....................- f <br /> 1_0 Oo <br /> Building Permit No. <br /> improvement Pian No. <br /> Supplemental Conditions: <br /> Conditions: <br /> r <br /> IShow sketch above or refo to da-Mg submined <br /> ll <br /> s all <br /> icable <br /> ity ordinances, <br /> fV,PORTANT: Applicant hereby agrees to comply with all Provisions o+o City permit <br /> actuo costafor removiol and eproperr replace- <br /> 'esolutions, stondords and specifications currently in effect, and to Pay . l will be muse for revocation of permit. Appii- <br /> menl of any iwi-n which does net meet above requirements. Failure to comp y <br /> :ant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> aersons, death of person or damage bo Proscnrted by aipR iaanthupoln te re��testof or 9s a result of work !o be performed under this <br /> 'permit. Certificate of insurar:ce <br /> ad Genera PEavlalons on reverse side of this permit before signing. `Note teaufrement of notifications and Inspections. <br /> - perrnit£nglneerlinspector ` Phone( --- <br /> 5ipnsd: <br /> su.eaofl <br /> gum <br /> r <br /> ' tno--•Fde ],A--Frnance afh-..UnIdY/street <br />