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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M <br /> pAppppbcanYs Name d C�z G -� N`a:;-R--C LSYILIEL ha_Date <br /> (OwnedContractor) hG <br /> Address ?� i4`= 1111_zr"6-t5•t Phone_/CL V8` <br /> �—"'•" APPROVED: PUBLIC WORKS DIRECTOR <br /> city L t�'N C 6y-Ac kA __ _State Gly Zip 906 <br /> Location of Proposed Work,etc. LA 0 0rJ Y=L_ D 0 R.&n o .e 't- <br /> k4er, .4, ct G. -4C,Z- <br /> Owned contractor Address By Date <br /> Estimating Starting Date Comptetion Date Permit Expiration Date <br /> I(or We)hereby apply for an enroachment permit to carry out the following work: rco„ r <br /> r1# ;ee n M n <br /> The above named applicant hereby requests permission to- l Z <br /> G '� <br /> PERMITFEE..........................................S <br /> Additional Footage Fee...........................S <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 <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 currently 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 agrees to 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 7AyA=•'1RE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUNp UTILITIES. •:.'; <br /> PERMITTEE SHALL CALL(209)937-844.44Z-HOURS PRIOR TO START OF WORK FOR A CP.4.1-rMNUME i�-* SCHEDULE <br /> INSPECTION. to <br /> Read General Provisions on reverse side of this permit before signing - Note requird • e� m <br /> tiCddtjo:-.i and inspections. <br /> Signed •Rhona: <br /> tst-Permitlee 2nd-File 3rd-Finance `41h-Ublity/Street <br />