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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 6 55 4 y <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> A plicanrs Name .` CI�Mor1` a1�f(Lc) D <br /> ate `9om <br /> (Swner/Contractor) C � LAddress \im _ Pl oc) -C} <br /> 3 <br /> city PtCLOIX-Inton G <br /> State �_.._ Zip �i`-IG�r3 APPROVED: PUBLIC WORKS DIRECTOR <br /> iLocation of Proposed Work,etc. <br /> 3� `�` Vfrgi r n . rif' 1 <br /> Owneri,Co�acto� dress ~�;F C 1(. I j I'" 7 r VC bi r B . " ,. 1, Date_ <br /> L�� irLr - r�r7�c n f , cam► C� ! <br /> Estimating Starting Date _ Compietion Date Permit Expiration Date <br /> IU41rc- <br /> I <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: <br /> AT , a c i�z �rG %t %rte.C �frr <br /> �ri o <br /> I <br /> The <br /> I <br /> aboveapplicant hereby requests permission to- PERMIT FEE................... .....$ k L- <br /> 1 i <br /> ' Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT.............$ <br /> I <br /> 1 Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> r3c:�.�t��c.Z tz�t� �e '�t..L Ciltl�k �,�;K�+�r G�•;, c.L,:�, <br /> �f.kl't <br /> 0CI. X21 or hetru cch�a� i~�. <br /> 1 Z� 5r �K 1C�I `�- 5�tall ccrt 4t:ren L,-'.'rCJy <br /> E 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 e`.fect. 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 (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> RK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> MITTEE SHALL CALL (209) 997 6411 24 1 QIJA&PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. �3`1S3(dp 4`6 HOUFi5 <br /> Read General Provisions on reverse side of this permit before signing - Note requirement{f of notifications and inspections. <br /> 60, <br /> Signetl: 1 /`-\.' � �.` �L Phone <br /> 1st-Permittee 2ndLFFle 3rd-Finance atn-Utday/Street <br />