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10 / 02/ 2000 17 : 14 209467111 ,1 AGE STOCKTON PAGE 02 <br /> CITY OF <br /> DEPARTMENT OFF PUBLIC PUBLIC WORKS <br /> �./APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OFWAY <br /> Applicant's Namej�9•n�,Lt'XEYS—�( �� ^^—C& Date ` 2✓ �u <br /> (0wnancontracto0 `` f1 �� op4 ! T 4 rf.r i <br /> Address /VO �� y/Phone A&V6 <br /> city C , LTAPPROVED: PUBLIC WORKS DIRECTOR <br /> trals <br /> Lomilon of Proposed Work, etc./ <br /> Owner/ Contractor Address P ✓ Date <br /> Estimating Starting Date rb iD Gomplation Date r � b en-nit Expiration Date <br /> I (or We) hereby apply for an enroaehment permit to carry out the following work: <br /> /nApe <br /> Srze <br /> ---- � <br /> The a6ov2 named applicant hereby raeueeb Pelmle9lon ro - <br /> �l PERMIT FEE ........... .......... .......... $ <br /> � �- Additional Footage Fee ---........... ............. $ <br /> Sewer rap DepoSlt ...4.............................. <br /> TOTAL oEPoslT 4... ......... $ W✓r ~— <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> rt <br /> show skareh AM%ra or refer to drawing eubmlttea <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 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 /> ii WORK FOR LOCATION OF UNDERGROUND UTILITIES- <br /> PERMITTEE SHALL CALL (209) 937 A 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 signing - Note requirement of notifications <br /> //'] and <br /> 9 inspections, <br /> Signed ,�, i.� Phone: !v ` /`�^-' <br /> 1eFPermittee 2nd-Firs 3rd-Finance 4111-13lil'ity/smear <br /> I <br /> f <br />