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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> —��^' N° 61597 <br /> plant s tla �Datr_ <br /> fOwnar/Contractor) <br /> tion of Proposed Work,etc �p I. APPROVED: DIRECTOR OF PUBLIC WORKS <br /> /Contractor Address 8 Date <br /> —ted Starting Dote—1�� �Completion Dote Permit Expiration Date <br /> Nor We) hereby apply for an encroachment permit to carry out the following work a 3 <br /> The above named applicant hereby requests permmi*n to- PERMIT FEE $ <br /> Addittorial Footoge Fee <br /> Sewer Top Deposit <br /> TOTAL DEPOSIT s ZtJ <br /> Building Permit No <br />' Improvement Pian No <br /> Supplemental Conditions <br /> Show sketch above or refer to drawing submitted ti <br /> PORTANT Applicant hereby agrees to comply with all provisions of this permit as welt as all applicable City ordinances, <br /> solutions, 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 Applt- <br /> Int agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> rsons, 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 /> ad Generaf Provisions on reverse side of this permit before signing *Note requitement of notifications and inspections <br /> Perm lt,9094umWinspector <br /> 944-8825--00 V71:? 0(f f:V-V�76-t- <br /> 66 Signed 1Zne_ + <br /> �o�s <br />�trr^itire 2ttd—File 3rd—Finonce 4th.—Uttitty/Street <br />