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13:.3b 1b34671118 AGE STOCKTON PAGE 06 I <br /> CITY OF STbCKTON <br /> DEPARTMENT OF PUBLIC WORKS06WA 6564.3 <br /> APPLICATION FOR ENCROACHMENT ON PU13LIC RIGHT-OF-WAY <br /> CD2/59y� <br /> ADWIcanYS A20 <br /> Name Date f /ZZ <br /> ( neNContra r _ ' <br /> Aadrsss (/" Phone /`V ICS <br /> i <br /> city Sate ZID APPROVED: PUBLIC WORKS DIRECTOR <br /> Location or Pmposed wvrk.etc. `7 <br /> Owner!Contractor Address 110 ey Date <br /> EEtirttaOrtg Starting DateL compiafion Date 1 W PermR Expiration pate OD <br /> I(or We)hereby apply for an enroachment permit to carry out the following work: <br /> i <br /> a <br /> I <br /> The ebm ream"mmilcant hereby reweaty perrnberom to- PERMIT FEE...................... <br /> Additional Footage Foe...........................S <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT.............S 12 .. <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> � � Iaavr-t'tte+tV� i�W�t�(a <br /> Snow tnc#tcn#f70ve9r r#rarte tlrawitQ#atXnmeq <br /> IMPORTANT: Applicant hereby agrees to Comply with all provisions of this permit as weV as all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be rause for revocation of permit. Applicant agrees to indemnity and hold the <br /> City harmless against arty and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> occuring at the site of, or as a result of, work to be performed under this permit. A certificate of insurance shall be submitted to the City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-804642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FQR LOCATION OF UNDERGROU,NDD'UTILITIES. <br /> PERMITTEE SHALL CALL(209)937OURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION, d0 <br /> Read General Provisions on reverse side of this permit`.(before-�s"i'gning - Note requirement of notifications and inspections. <br /> itsrr , <br /> S�pnvd: , vnone. <br /> tar-Pam+Rtea ZMO-Ina 3rd-e;mar,ca am-Utnrty/Treei <br />