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Q CITY OF STOCKTON 64352 <br /> DEPARTMERIT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-DF-WAY <br /> Applicants Name —6,xT] —'z Date(Owner/Contractor) -Address_.�r3��/ <br /> =9/ <br /> Phone <br /> Location of Proposed Work etc APPROVES] PUBLIC WORKS DIRECTOR <br /> 4 w' a oC ntractor Address j �A 15"";AVE 4s <br /> Y— � 6-4(L Date <br /> Estimated Starting Date Completion oato ' Permit <br /> Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work ocG <br /> rdcccc.+ �� <br /> '4. IM' — I #"-- <br /> The above named applicant hereby requests permission to t71' <br /> PERMIT FEE g y'Z <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT <br /> I /�-TTj�Grf�L� <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> /,11 wz)2 ca St-��1LL t -c Qom' a <br /> �o W�C.�taC� wa`tk ptvLYl <br /> SIL ��►ti'L,1(�NFr '�flu'Z�` <br /> Show sketch above or rolor 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 <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 Z <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE-ALERT <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES (1-8Up- 2='2444) TWO WORKING DAYS BEFORE BEGINNING <br /> " <br /> P ITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> N� <br /> IMWCTION <br /> Read General Provisions on reverse side of this p`errmitbb/eefore signing — N`ote requirement of notifications and inspections <br /> Signed GCf3C_[/r _ '�C41L-- _ Phone CEJC(045/nf✓clp <br /> 1st—Permittee 2nd—FIC ,yM did—Fa�anc!''r 41h—UGltly/Street <br /> r <br />