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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant s Name— �'r�r=�l�_ K '--. Date_ .— 59899 <br /> (Owner,CantrottOr, �a SSa7 <br /> -- <br /> / APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc, /�t <br /> - 44.0. -w- /_ _ --- <br /> Owner/Controctor Address,,/ -- — _ —. - ---- By _Date j_.. <br /> Estimated Starting Date.C�C� z!T'1 Completion Date— Permit Expiration Dafe a y — <br /> I (or We( hereby apply for an encroachment permit to)carry out the following work: <br /> x1a_L�JCQ� <br /> The above named applicant hereby requests permission to PERMIT FEE E _-- <br /> Additional Footage Fee ---- <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT ._ 3 � <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, <br /> rpsollttions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> pArmit. Certificate of insurance will be presented by applicant upon request. <br /> Rend Genernl Provisions on reverse side of this permit before signing. 'Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> Phone <br /> • _�C����� <br /> 944-8366 Sign Fhonr - - <br /> III--Permittee 2nd—File 3rd—Finance 4th—Utility/Street <br />