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l <br /> P66A CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> �- APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant a �l�V��• K��1wLt Date 3 <br /> 1Llutuor onlractot <br /> Address D •�� Phan r <br /> Location Of Proposed etc APPROVED PUBLIC WORKS DIRECTOR <br /> Owner 1sr Address affinglaf fit6 r y Date <br /> Q313 c <br /> �h/o 3 <br /> Estimated Starting Date 1 (03 Completion Date mit Expiration Date <br /> I (or We) hereby apply for an encroachment rmit to carry ut the following work OL! <br /> r. <br /> •i-M At- a <br /> L e� row &f �1 ,t <br /> The above named applicant hereby requests permission to PERMIT FEE 5 _ <br /> Additional Footage Fee <br /> !` <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT S_ <br /> 3 Ss <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Show sketch above or werto 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 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 /> occunng 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 p r It before signing — Note requirement of notifications and inspections <br /> Signed —` — 1!>'/� � •�" �0�Phone(�ir6)4 3q'Zi� <br /> riaok �I�v:root lee-, <br /> ist—Permittee 2nd—File !rd—Finance 4th—Ut1J1tyJS[reet <br /> t <br />