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CITY OF STOCKTON <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# rr APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name L DAJ � � rl I9 <br /> (owner/ contractor) - - Dale —_ �— <br /> Address -I-x-33 ( 11�yvke, 44 livOPnone9lb - 9LR' 330 <br /> Location of Proposed Work, etc. _� 1 OA— APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner/ Contractor Address <br /> J4l 2l? 1 446 BY 6 t 1 Date�lf - �(o <br /> Estimated Staving Date Completion Date �rkZFs l [, Permit Expiration Date <br /> 1 (or We) hereby apply for an encroachment permit to carry out the following work : n <br /> r 'LAIC� <br /> eCl w , l ( C rhon ILS rr) �a c✓) c 2 - f� �i <br /> will he hc.L��, IIecQ , , 1-c, n c -1- ccvt� i� <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE . . . . . . _ _ $_� � p � O <br /> e0 Additional Footage Fee <br /> tSewer Tap Deposit . . . . . . . . . . . . . . . . <br /> O <br /> fL -D � • <br /> EL boe,4p0 TOTAL DEPOSIT . . $_ O � <br /> V <br /> Building Permit No. <br /> Improvement Plan No, <br /> NOMfac� Lan � <br /> Supplemental Conditions : <br /> �� o �GcQ <br /> e�� hn•irs p,J\� . <br /> o,fiu.&Jr, MCA{ <br /> Show sketch eye 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 <br /> the 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 <br /> City Risk Manager prior to beginning construction . <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800=94f 2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION , <br /> Read General Provisions on reverse side of this permit before <br /> beforee signin/g — Note requirement of notifications and inspections. <br /> — — — <br /> prone 9/6 - 928 - 3 <br /> 3 00 <br /> Ist—Permittee 2nd—Fite 3m—Finance <br /> 41h—Uelnylstreel <br />