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Mar • 28 . 2080 8 :51PM — _ No • 1071 - -" P • 2/2 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> -_ �y 1 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 6 ( 61 <br /> Appllram's Nome C �l(V!r ��ti�I� . /li:'CCji?bate - �d <br /> (OOwwner/Cefl/tfaCtCO /�^ JL.1� ,� �J �s <br /> Address 1 �Ci //-�'(��k (iU't�C•/'"CVC-k Phonez <br /> city -�~ c,�?z5 stare Zip. .S APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed W ,etc. 6 p <br /> Omen CohiradorAddlad4 r By Date __ <br /> Estimating Starting Date Completion Data 3 d permit Ezpireifon'Data <br /> t I(orale hereby pply for an enroachmgnt permit to carry <br /> out the following work: F--->c l <br /> 3 <br /> I <br /> The 2ww aamW aawlirtSmm-h�eropy r eele permisslw to- PERMfi FEE <br /> C !'''r' <br /> %/ ��'�" //""~arl✓1 .��1.jyf•..-•''-a-�t�'�,,....$ <br /> 7" t/ Additional Foo <br /> rage Fee...........................$ <br /> Sewer Tap D�it..................eC......,_ <br /> ` e- 1 <br /> TOT D PO .............$ r <br /> Building Permit No, <br /> e <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> i <br /> Sher sketch abve or rete to drewingeut R,.d <br /> I <br /> IMPORTANT: Applicant hereby agrees to comply With all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications curranfly 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 cause for revocation of permit. Applicant aglrepl ce indemnify and hold the <br /> City harmless against any 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 (1-800.642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> PERMITTEE SHALL CALL(209)937,-84M24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. F12fdp <br /> Read General Provisions on reverse side of this permit before signing - Note requirement of notifications and inspections. <br /> 8Lt5-1.J <br />