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{� 65046 <br /> Oak CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applican' ATC A nc;ot¢5 °Ai kbaii�i'rYr�Date 8 <br /> (Owner! ntractor r� �Qati) <br /> Address wwo QL_uan!5 riyQ Phone I-i -530 <br /> (2-- <br /> PjaatantonxA 945 APPROVED: PUBLIC WORKS DIRECTOR <br /> I Location of Proposed Work,etc. <br /> ++ll <br /> 3.555 W&"tNam T_rLane1Madnerf) ])tr_1(!I + <br /> �lContrector Address 1 SID mf. Imf ry ( Ba. � Date 4 <br /> i� `�50TE'l 42- t5¢ F�amo C!A 5 iR <br /> i9cEstimated Starting pate Completion Date Permit Expiration Date <br /> , <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> r� ATC p r n 4aii n n <br /> -� 1 n <br /> 1 [ n <br /> ' r <br /> m i <br /> 0A, <br /> nr <br /> The above named applicant hereby requests permission to. PERMIT FEE............... <br /> I,� +(�_ aA f)I +¢ plan . <br /> Additional Footage Fee.(f � Sewer Tap Deposit .. .... '. ' <br /> TOTAL DEPOSIT $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> nSupplemental 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 /> l 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 /> 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 <br /> City Risk Manager prior to beginning construction. W'Z <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800 -2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> 1 PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> eeadG <br /> SPECT'ON. <br /> eneral Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> Signed: vim _ - — %D-5 <br /> 1st—Permittee 2nd—File 3rd— mance 4th—UtditylStreet <br /> r <br />