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CITY OF STOCKTON w' <br /> DEPARTMENT OF PUBLIC WORKSCA <br /> 65548 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 1 Z I AV t.re-s v1n �9ate o Z 3 � l 5� <br /> OOwner/Co��{actor 5233 <br /> t! <br /> Address f .0 60k J Z 3 3 Phon gam✓ 9�o <br /> City l/1'" C State � Zip 933 g g <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Pro sed Work,etc. 340 E S <br /> fvc f 6-z5-w S. <br /> caner/ ontractor Address �"'�UI� lin i0W73 Date <br /> Estimating Starting Date el lot 1 CompletionDatem AllsiRF I Permit Expiration Date <br /> I(or We)herebyly for an roachmen permit to carry o the f Ilowing work f <br /> !P_ss, <br /> RA q Is <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE..........................................$ <br /> Scotch©7664"Post-it"Routing-Request Pad <br /> Additional Footage Fee...........................$ <br /> ROUTING - REQUEST Sewer Tap Deposit................................. <br /> Please <br /> f TOTAL DEPOSIT.............$ Z <br /> ❑ READ To )�e <br /> ❑ HANDLE J Building Permit No. <br /> ❑ APPROVES( ��•,�Q Ccimprovement Plan No. <br /> and <br /> E] FORWARD 511 f <br /> 7 Supplemental Conditions: <br /> ❑ RETURN � <br /> ❑ KEEP OR DISCARD �P_a C O VN *f `/�T'-7"/( <br /> r <br /> ❑ REVIEW WITH ME y/1 <br /> Date From <br /> i <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 /> 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 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 /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)x-64# PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. g37'�0w `� 5 <br /> Read General Provisions on reverse side of this permit efore signing - Note requirement of notifications and inspections. <br /> r �g16, q3` <br /> Signed: A Phone: -2-170 <br /> 1st-Permittee 2nd-File 3rd-Finance 4th-Utility/Street <br />