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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-IIVAY <br /> A90dCWIS Narve 4. r Date APPROVED BY THE PUBLIC ECTOR <br /> Owner/Contractor) <br /> ;cdrass r •-1 �C; y-t-r v. -�- _ Subject to the General Pro stens and Sc=cial Conations anq all <br /> _ , _-Pt,on � 3 C"i Y wove must,cnrcrrn to;he owier, s 3oprc jeC Sterrn NaterPLiluttrn <br /> Stase r< Zip_�� :1-7( Prevention Plan or the C tv DT vrockicn Sic rm','later c3olh,00n <br /> P,evennen Maintenance&tat;uuule &ric-laser is aopecable <br /> _ccaLon of;:'r000Sza Work etc <br /> Cwnerr Contrac or Address ++ -' _---- — -- SyG <br /> stlmating Starting Date —_ -7�2,-3 Completion Dair - �arm11 Exprraticn Dale <br /> ' I (or We) hereoy apply for an Encroachment Permil to carry out the followtng work - <br /> ` J <br /> '.LL <br /> ..,.�. t: ��% - t>t - ..-. _ r --='cam- �.,_ L <br /> t <br /> ' The awve names apoDcanr';eopoy renuem <br /> srs deras;ion 10 W T <br /> PERMIT WEEP- <br /> 0c) <br /> EE <br /> r <br /> i <br /> Additional=ociage Fae 5 _ <br /> 0c •f 1 Trgnr�Fee <br /> J <br /> S tier Tao,~.epos l _ �Y <br /> TOTAL 3E�'GS1_. <br />' e Building Feimll No ---_ <br /> 1 Improvement Plan No <br /> I <br />' I Sucolemtental <br /> 1 <br /> I <br /> ltew,helot auove i r reler o]rawng suomineu _ <br /> IMPORTANT Aooucani nereov agrees ,c TCMDIV with all provisions -r his permit as+veil as all aCaiscaeirr Crrr -r tlrar-as esclu[la-,s <br /> Srar+dares and Spec frcatrons Purrentiv to effPci and ro oav•o the Cat, its actual cost for'emoval and crocer rr+e'acer^ar, ,r 3nv 'em Vnlc, -C-s <br /> _,:.r -nret the a0ove equlrements ^3rlure to commy Nrli be cause for tevor-ab,)n of permit aRpor.ni 3911--s o raemr- ]r-- IGC ne C' <br /> %a_nsess against anv and all-csses :csts or damages resulting trcm n'uy to persons 7eath a,erscn or 3amagc c�rry :�c-_jr,.ng at tie ;u= <br /> ,r x as a result or vork 0 oe pert_rmed unaer'his permit A cPmttcate r: nsurance shall De submitter,,r he C N ,x 'Aaragel or or o rssuarre <br /> 'I res DeML <br /> mSR -MITSHALL CALL 1209)937 8366 FOP A CONTROL NUMBER `�O LESS-HAN HOURS T NOT rJ =(CESS C F -2 -CLP5 <br /> 1 <br /> aRICA TO TWE START CP /YORK AND -RICR TO ANY REOUtRED-NSPECTIONS AS IDENTIr'EC ON THE FE E^:E SICE =r= ---1S <br /> 6=I1MIT IF WORK DOES NOT BEGIN WITHIN -2 HOURS OF THE ISSUANCE OF A CONTRCL NLUBER THE _ N'�CL JL.MZER "Irl._ <br /> f,A^ E INVAL D AND-r-E zlFRMITTEE SHALL CALL FOR ANE fJ CONTROL NUMBER iFvm CAPITAL IA� R <br /> PC r EME IT FCC-ECT.S C� <br /> CIVISICN IMPQCVEMFNTS aERMIT-EE SrALL CONTACT THE ASSIGNED CITY PRO..EC'= IGINEE:;AT 2D9, ?37 a4 =CR <br /> F C INSTRUCTICNS ORIOR TO THE 9EGINNING OF aN`r NORIA <br /> READ GENERAL PROVISIONS ON 91EVERSE SIDE OF THIS PE9MIT BECGRE SIGNING <br /> _ - ?ti <br /> signe <br /> d�L�'.�_�T�*-t'Y`�--V�- rttr�4— er.. <br /> rsl PenmlrtPP wruter -4A 1^°r>^ ^t z n 3rd File c/aUn+., 4th I-nance lwrtlle I <br /> XVA 9£ 91 TO/TZ/60 <br />