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C4-,--,l of StocktonPW-Permit (2['' 937-8901 P. 1 <br /> Apr 09 03 10: 13a <br /> ---- 63388 <br /> CITy OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> x <br /> Apptican' Na <br /> �p{4K Y K� MQw I ►t G nate _ —..� <br /> 1,I�yGiyr pnl[aGlOr / t II �� PhOI' S'�-�r-�1�-r-- <br /> Address #�'rlr� I�i �t APPROVED_ PUBLIC 1NC1RK5 DIRECTOR <br /> �f Parte a G}4 a5�-�� <br /> Location of Proposed Work,etc. <br /> luyvlP ��K 60{�ror�-d# 2 t] �, rwt r L% . ` L <br /> V 1_ f t �H vale <br /> Owner 6er+kaetOr Address D�7 13yj O y -- <br /> I I O completion Date 4 { ()-3— rmit Expiation Date <br /> Estimated starting pate <br /> I (or We) hereby apply for an encroacfitment rmit to carry out the fallowing work <br /> OH YOV -Do P <br /> V k <br /> e t uRo tP <br /> 'IF P.0 -� r h 'cam of <br /> MU 2 <br /> The above named applicant hereby requests permission to- PERMIT FEE.... .... ......... $ <br /> rt l f�G � ]_ ��� Additional Footage Fee-. <br /> e - <br /> 4t rJr �j E' sewer Tap Deposit .. <br /> TOTAL DEPOSIT ... - $_ <br /> Building Permit No. _— <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> /az <br /> Show sketch above or rater to drawiN ellbmdted <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 whic" <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and holt <br /> the City harmless against any and all losses,costs, or damages resulting from injury to persons,death of person or damage to prnpert) <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 th( <br /> City RislManager prior to beginning construction. <br /> k. PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-842-2444) TWO WORKING DAYS BEFORE t3EGINNINc <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 SCHEDUL <br /> INSPECTION. <br /> Read General Provisions on reverse side of this p it before signi(/ng_,— Note requirement of notifications and inspection <br /> 9gne 'if� 1 1�f41 UA'.�. "'6�0 <br /> 1 <br /> 1St–PermdSee 2ntl—File 9rd--Finance 4lh—U tihlyl SlreeS <br />