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Rb- <br /> CITY OF STOCKTON <br /> AP DEPARTMENT OF PUBLIC WORKS <br /> ° APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant s Name Date�',"J'/'I r.- I�O pap 7 <br /> (Owner/Contra��}�t, .7 ,� �f <br /> Address _ tr t' f r .221 2 1� <br /> Phon� <br /> Location of Proposed Work etc APPROVED PUBLIC WORKS DIRECTOR <br /> Owne Cpnlraclor Adgress �L <br /> �' •n ?7 By <br /> Date — <br /> Estimated SIarEing Daie ��_T _ 9 <br /> Complettvn Date L'Id—� <br /> Permit Expiration Dale <br /> I (or We) hereby apply for n encroachment permit to c rry out the foli work <br /> 413e- �•'jj rA-e Pu <br /> I Ir 1401 to a ! u L°/} eG7 rd ALJ <br /> t, — <br /> r <br /> e <br /> r--- <br /> f . <br /> w <br /> — mak G��rk G I <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE c ti2g I <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT 5 g� <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> - <br /> d-r/Tra/ <br /> c9 2- 0 -3 <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 o,dinances resolutions <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replarement 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 to the damage to property <br /> occuring al the site of or as a result of work to be performed under this permit A certificate of Insurance ;hall be stl <br /> City Risk Manager prior to beginning construction bmltted <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800444) 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 /> PECTION <br /> ead General Provisions on reverse side of this p(erMtt�bnefo a sig ing — Note requirement of notifications and inspections <br /> Signed V W-�.` � <br /> Isi—PF rinq[gc. 2nd-1`0e <br /> did—Finance <br />