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r r <br /> L! <br /> CITY OF STOCKTON <br /> DEPARTMENT OF. PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> . �� Mme ���;��zt-� ��• ���,��u�� -�/�,/� 57614 <br /> ;3 tL�ile% Phone 9:5)1IG <br /> �� r r`G � p� h �`� ���� APPROVED DIRECTOR OF PUBLIC WORKS <br /> ftoposed work tic i1 <br /> gy /J ///�ilec./ ---Dole <br /> -� — <br /> ' rWor Add.ert <br /> Stoning Dore <br /> iL CompSelion Dale '�� Ftrm�t t:.pact.on Dc}e_.., <br /> Y ` <br /> y�M hereby apply for an encroachment permit to carry out the following work C 1 Y <br /> 1 <br /> The above named appp=rront hereby regwes's permiss.on to FFRMIT FEE 5 s iI <br /> /0 Z Add,t,onol Footage Fee <br /> Sewer Top Deposit <br /> TOTAL DEPOSIT <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions /,2.� <br /> Show sketch above or refer to drow,ng svbm,ved <br /> � RTANT Applicant hereby agrees to comply with all provisions of this permit as well 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 /> 'nt of any Item which does not meet above requirements Failure to comply will be cause for revocation of permit AppII <br /> 'M agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from Injury to <br /> "sons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> emit Certificate of Insurance will be presented by applicant upon request <br /> tad General Provisions on reverse side of this permit before signing 'Note requirem t of notifications and Inspections <br /> Permit Engineer/Inspector <br /> 9448492 <br /> 9448366 S`9ned Phone <br /> �e+m,Hee 2n4—F,1e 3rd--F,nance AIF -Vtrtity/street <br />