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- -�s <br /> A90 <br /> CITY OF STOCKTON. ,s. , I.Jz: 6 3 61 <br /> DEPARTMENT OF PdOLIC;WQRKW r. <br /> APPLICATION FOR ENCROACHMENT ON PUaLIC�IGHT-OF-WAY <br /> Lac(^ , �� Ii+ ; , 17 14- G5 <br /> q f r, 4 J <br /> nt's Name -�� S VIG�,1�Ct5 e- Date <br /> (Owner ��y/• �-- <br /> ddress O � S� 1G Phone -A4—J 77/ <br /> ��}} APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. —dC � �/ i�frr�pl'l7f- H�()/+te <br /> 221" %.ct 0W In e _ <br /> Owne Gontractor dress S'C! ni �J �L±— t By Date �/ Q <br /> Estimated Starting Date 7- S— Completion Date 11-45-9S—.__ Permit Expiration Date -Ai-,31 - 257 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : lace- Q iMLiX 1 iii 1i o <br /> 5t7;I he trE' f- «t1C. CAi 4 <br /> t 1 u Ur , kA L 0 <br /> ' ll 1 r~La i '6 0-14c F r p A0✓r' <br /> The above named applicant hereby requests permission to- PERMIT FEE <br /> 0"101 tied Map 5 u'Izvflny , <br /> Additional Footage Fee... .......... - <br /> Ia� ' � of j%tU��S. Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT....... . $ C ti <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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 <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-842-2444) 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 permi Aefoigning — N to requirement of notifications and inspections. <br /> Signed: ----- - - - - - - Pno��J�il / <br /> tst—Permittee 2nd—File 3rd—Finance 41h—Ulilityl Steeel <br />