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I <br /> U I <br /> ' CITY OF STOCKTON U j <br /> DEPARTMENT OF PUBLIC WORKS �t <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 1 <br /> i <br /> Applicant'a No <br /> IOwner/Connq�tori � Date__ <br /> Addres �y0 Phan /6 37A-L v I <br /> t.ocotion of Proposed Work,etc_H67 E, ��4' iH �,/� APPROVED: DIRECT R OF: PUBLIC WORKS <br /> �-7- /'y- Y'{. ', / <br /> 5_Tf7C IC/DN � Crt ////X/ <br /> /! 't <br /> Owner/Conrroctar Address "' < Dalse I — � <br /> 8Y <br /> Estimated Starting Date /completion Dole rtf J IL I 1 �� Permrt Ecprotian Dote <br /> I (or Wel hereby apply for on encroach mens permit ib ca/try out the following w9rk: - f ' Il'T <br /> _ t <br /> I <br /> I <br /> Ij G! <br /> The above named 1 <br /> applicant hereby requests Permission to PERMIT FEE I (+ <br /> Adddlonol Footoge Fee, �I <br /> Sewer Tcp Deposit <br /> TOTAL DEPOSIT ?1 `) <br /> r I - _ <br /> Building Permit No. <br /> Improvement Plan No. � <br /> fl <br /> Supplemental Conditions: l <br /> d <br /> pr;L) G C; , , ;1, <br /> I <br /> t •Show sketch above or refer to drawing svbmined _ <br /> G IC h 7. L <br /> 1 <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinance: <br /> resolutions, standards and specifications currently in effect, and to pay to City itsactual cost for removcl and proper replecs- <br /> ment of any item:which does not meet above requirements. Failure to comply will be cause for revocation of permit. Apc: <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from. injury sc <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performedFunder c �i <br /> permit. Certificate of insurance will be presented by applicant upon request. I lilt <br /> Read General Provisions on reverse side of this permit before signing. *Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector 1 <br /> I <br /> -Y-944-8250 <br /> 944.8366 'l Sinned <br /> I <br /> C <br /> Col <br /> cI t--- l i I j <br /> l <br />