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J <br /> © CITY OF STOCKTON C J <br /> DEPARTMENT OF PUBLIC WORKS <br /> ►+ APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name F a 1f U a �m v'r r tl i,i Nt rM Date > + <br /> (Owner/Contractor) vib C .7N V't -yy��? zJL <br /> Address (eunci,t M w r( �,(ti [A $�t $ Phone 9th ZS L <br /> Location of Proposed work, etc. �`t ,S. irk tlit Am h }ti' S trt ft T' APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner/Contractor Atldre55 Sq h 'r c"ith 61 N b�' % T'� e Z"q• p)• ). •os-� <br /> // 1 e Y -L. Date <br /> rn <br /> Estimated Staving Date 9,if (� 1 , T Completion Date 9 I t t' , 9 } Permit Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : P45 h - �'o i � '�' S v� b ori tig <br /> OF i tAct, 411,1" tyte iii City Sid < wallk for cvllect-ich of soil tkr{ <br /> V <br /> <I'�oHhAwa }t,- cR>MPI �s fur 2Nv ''rca�tet7F11 Pu•rPeses <br /> V <br /> V <br /> The above named applicant hereby requests permission to PERMIT FEE.. $ <br /> Additional Footage Fee <br /> V <br /> Sewer Tap Deposit ........ ........ �j�a, <br /> Lr TOTAL DEPOSIT ..... . $ 12 V <br /> Building Permit No. <br /> Improvement Plan No. <br /> V <br /> Supplemental Conditions: <br /> t. HO 'CQs+a�EL �VEa �rAev-- �rE <br /> L" B�OUGFp A.'C ns.Y-C "C"\t�,E l�l»VJL'� <br /> T412 COQ\e_�t= � -•t'y4�S V+b2�. <br /> rr 2 SeCEwt>.�1� G\J7�1]t2.,F SMh\.�_ �A•�[y,• <br /> Zn W <br /> Show sketch above or refer t0 drawing submitted <br /> V <br /> IMPORTANT:Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> V 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. &4V- <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1.800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION O D UTILITIES. <br /> PERMITTEE SHALL C L(209)937-8411 2 OURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> ` / ytb132Sa <br /> Signed: 3C— _. � _. —. _ PM1one`___ (_�_ <br /> 1st—Permittee 2nd—File 3rd—Finance 4th—Utilityl Street <br />