Laserfiche WebLink
CITY OF STOCKTON • C /, <br /> DEPARTMENT OF PUBLIC WORKS V J 8 J (t_ <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name i�'uVM,c Geo Bhullv�ca xt.x�a� Date %4-�6'00 <br /> (Owner/ContracI <br /> Address 406 �•k"1lSo+. Way Phone Lio-toot <br /> city S T6& JO&I stateGA. zip Mo li, APPROVED: PUBLIC WORKS DIRECTOR <br /> Wf, 1 r.tlloH f <br /> Location of Proposed Work,etc. 3 DO b 1ecK of s L . <br /> Owner/Contractor Address l B Da/t'e e,�k� <br /> Estimating Starting Date 44-31-0c) Completion Date -t'�1 i 0 G Permit Expiration Date `�'3J-v 6 <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: <br /> O--%z 50; I b0vl1k9 tyt gapKlka late L - to b< ba,KNUacl utero comlb1iol <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE..........................................$ N <br /> Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................ �, <br /> TOTAL DEPOSIT.............$ hll Ur <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Co ditions: <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 indemnity 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 DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209)937 Q4 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. 1 of <br /> Read General Provisions on reverse side of this permit before signing - Note requirement of notifications and inspections. <br /> Signed: XA1.k�P�� Phone: -1 V z - 100 6 <br /> 1st-Permittee 2nd-File 3rd-Finance 4th-Utility/Street <br /> v <br />