Laserfiche WebLink
'll <br /> CITY OF STOCKTON <br /> DEPARTMENT O'` PUBLIC WORKSAffi <br /> I" APPLICATION FOR ENCROACHMENT' ON PUBLIC RIGHT-OF-WAY <br /> h ' ! U N° i61344 <br /> nt's Name Afais. Cny,`r{}� Date1-2 — h: <br /> Owror Gomractor S �� .11e CA Phone L-7—/ia <br /> res .� APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc i' + <br /> 1610 tat D m cLo 61U 7 o ux l lS h G <br /> oa A I Llf•1 <br />: Contracto ss O IDOY '70-7-3 � BY <br /> owner Addre <br /> f Estimated starting Date ompietion Date Permit Expiration Date r <br />� vpNize� W/717, ' rl f� 3So � 6pr 'n S Trr ' <br /> r *aar Wei hereby appiylfor an encroachment permit to carry out the following w�c, <br /> !j ` er b S Cin "kJr < S. <br /> r ro <br /> 04h <br /> lil _ e <br /> The above named applicant hereby requests permission to - i PERMIT FEE .......................:.........._-...-... .-- $ <br /> i <br /> Additional Footage Fee.... <br /> I Sewer Top Deposit ..-- ....... - r <br /> a <br /> y � TOTAL DEPOSIT ....:--....:.........:' S <br /> Building Permit No. <br /> Improvement Plan Ne <br /> Supplemental Conditions:b <br /> Show sketch above or refer to drawing submitted t' `'z "" 4" i <br /> ,iii <br /> IMPORTANT. Applicant. hereby agrees.to comply with ail provisions of this permit as well as all applicable City ordinances, <br /> I. <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 whith 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!rsite 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 signin Note requirement of notifications a nd"inspections. <br /> Permit Engineertlhspector <br /> 944-6250'11 i R�6 ` /-n <br /> 844•$366 : Signed: 24--e Phone <br /> .I <br /> lit—Fermittee 2nd—file ' ''3rcF--Finance 4th—Utility/Street <br />