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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 5 <br /> AD APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> u9� <br /> ,��ppuplIu�rtt'sNiame 748 <br /> TL Assoc.;. 4-% km- Date 3 9 bo �D <br /> (Uwner/cortra d 1�l.. �UVL ( Ste' 5- <br /> A-- <br /> city <br /> 4 IJU t !lilt 20 flM 1107 <br /> Address Phone — <br /> city_AQCV--% _State tA zip cMas APPROVED: PUBLIC WORKS DIRECTOR <br /> Location or Proposed Work,etc. 5 ic4Wo kV, J- u'J <br /> knkn-ps <br /> towner/Contractor Address l i Ljnv L- k ` Date /o <br /> Estimating Starting Date Completion Date 3�uoj0 <br /> Permit Expiration Date Z <br /> 1(or We)hereby apply for an enroachment permit to carry out the following work: Lm6kk Giv, Z— w&kA <br /> ^Q%k- wr, Irl �-11.1. s t wo m� f-1 rd-ti► s c [ vr]i <br /> iS *A, QIA� A-1N. S.> .1y ScLu o- ,�t K Co. tF-tl j . <br /> 1 C�Ivl4 - <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE.................. .........$ <br /> Additional Footage Fee...........................s <br /> Sewer Tap Deposit.......I......................... <br /> TOTAL DEPOSIT.............$ Oo <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 indemnify and hold the <br /> 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 City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-804-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUgN�UTILITIES. <br /> PERMITTEE SHALL CALL(209)937�.2�HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. zftko <br /> Read General Provisions on reverse side of this permit before signing - Note requirement of notifications and inspections. <br /> Signed. +"''" Phone. Lam' + S7-4—7Z <br /> 1s1-ParmRlee 2nd-File 3rd-Finance 4th-Wiily/Street <br />