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J CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ' N° 62322 <br /> ant's Na fS� Date 1s <br /> r/Contra7ctor)Q r �'U.77�-o y oro aq�r16Sa <br /> Addtes t�t/4�dt><7 CA q� Phon APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. <br /> ' Owner/Contr or AddBy Date �v v <br /> —z Address 1 c� <br /> stimatpd Stu a Completion Date Permit Expiration Date <br /> i <br /> I (or We) hereby apply for an encroachment permit to carry out the fo wing work rI fro r' <br /> n. A Ive f M 6 <br /> s <br /> The above named applicant hereby re9uests Permission to PERMIT FEE .............................................. S1 <br /> tAddihonol Footage Fee. .... .... ... <br /> Sewer Top Deposit .................................... <br /> !A <br /> TOTAL DEPOSIT ........................ S I� D as <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 /> resolutions, 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 of the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> 1 Read General Provisions on reverse side of this permit before signing. "Note requirement of notifications and inspections. <br /> permit Englneerl Inspector <br /> ()�,J 4M4-8250 fd--) J; <br /> Signed: . / Phan <br /> ?Z-1- <br /> p&Z t@ 0 U� <br /> 1st—Permittee 2nd—File ]rd—finance Ott—Utii,ty/street <br /> e <br />