Laserfiche WebLink
CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61597 <br /> Applicant <br /> /contractor) <br /> Ph.ne�71/d�6 �� <br /> t—tion of Proposed Work,etc,_/C -51<9 40" APPROVED: DIRECTOR OF PUBLIC WORKS <br /> '60rf'C�' <br /> r>­/Ccmtro&or Address <br /> r%#i_ot#d StartingDote._.,,,: :- . . . .Completion Expiration Date- <br /> (,-)r We) hereby apply for an encroachment permit to carry out the following I work: <br /> The nhnv* rm-od ripplicont hereby requests permission to PERMIT FEE <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT ..... <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted Fly <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 EngineeriInspector <br /> 944-8250 jz!i?-f ve <br /> 944 8368 Signed- Ozz)A <br /> .90'p-5- <br /> I,#- <br /> 90'p-5— <br /> I,#- PP'_'tl'e 2nd—file 3,6—I'monce 4th—Utility/Street <br />