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CITY OF STOCKTON 64365 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AF�, (//, APPLICATION FDA <br /> "ate ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name !'NC 1 — �+ Nv7L-Date __L_ -7 <br /> (Owner / Contr <br /> Address l-Fpj✓ AjgLc.ryi L—N _-__ Phone <br /> Location of Proposed Work, etc. APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner/ C 1 ctor Address Wer:14 e-t f(J_�5 �� By— - - - . (oQ_'L4'-� Dale 1 J _✓� <br /> t7 /s <br /> Estimated Starting Date ,���/ _ Completion Date `� / �— Permit Expiration Dale S " 10 <br /> I (or We) hereby Apply for an encryachroent permit to carry out the following work : owl <br /> - - rLti✓il�.� Jl ') Gt7 moi"•-1txttN7�- S�iS��l`'. v J• <br /> I - <br /> The above named applicant hereby o <br /> pp er y requests permission to PERMIT FEE . . . . . - $ _ <br /> A6' lr _ , \^' /�>. `1 Additional Footage Fee . <br /> rI / VF{[it-GL J / �(L7/�J Sewer Tap Deposit <br /> TOTAL DEPOSIT . . . . . . . . . <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Oor, C Shall be res Fried <br /> 40 en' lci � lark cyl /i . <br /> an C( CW , 'alla-ed - <br /> Show sketch above or refer to drawing submilted <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 . (pQ� <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1 -800.6422-2444) 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 /bbeeefforree signing Note requirement of notificationsand inspections, <br /> Signed_ W /C�E�`�[�✓ ' .'t`li4[-.f - Phone/ 5til . -t <br /> f. tot Prnn,tlno 2nd—File 3rd—Finance 41h—Utililyl Slreet <br />