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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT SJJ7 <br /> N! 6t6 <br /> I" fft� L . .4LE-SV15. Date 3•.z/—`l� MAR 2 21994 <br /> Ager..• l �. Cv. .fa[EEF LAJ mss¢,/ .0"' <br /> PERMIT/SE I <br /> Location of Proposed work,etc—�/ay.Ll L/C. — /c/l� /.[J• fiffYl A ROVED:EN SEIW" WORKS <br /> STaGl�DN� �� <br /> OrnerXentroetor Address SY Dar - / " <br /> 74 <br /> z J/A <br /> Estimoted S oo" �Completion Dot Permit Expiration Dare <br /> I (or We) hereby apply for an encroachment permit to carry out the following work: <br /> / -27VO S- i(JCs� RJG 1vtZLs //L <br /> eftddni'� 7D /3-S 4V "61%'W/444- <br /> 11V <br /> /N iJ446 <br /> The above nomad applicant hereby requests permission to• PERMIT FEE.......................... ........... S 1W co <br /> Additional Footage Fee.... .... .._. <br /> Sewer Tap Deposit .................................... <br /> TOTAL DEPOSIT ........................ S �— J 106 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted cv, I } I <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. ote r u nt of notific tions and inspections. <br /> Permit Engineer/Inspector <br /> 9 3l 9"-8250 'a e.a <br /> Signed, Phone <br /> 1st—permittee 2nd•-File 3rd—finance 4th—Utility/Street Q <br />