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© CITY OF STOCKTON <br /> OEPARTNI_ ��F, U� C.WORKS <br /> APPLICATION FOR ENCR �IIAENT�NthUBLIC RIGHT OF-WAY <br /> Applicant's-Ma= l�T1Y//�L //j/ Date <br /> (Owner/ ontra r) <br /> Address <br /> Location of Proposed work,etc. -__13 � AMIA) ST/I�1 APPROVED: PUBLIC WORKS DIRECTOR <br /> Owne Contract Address—o:—S,~ 19S s4961,4" / q By'A <br /> Date <br /> /4. Co!J �)Estimated Starting Date mpletion Date _ <br /> permit'Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work':', <br /> The above named applicant hereby requests permission to. <br /> PERMIT FEE..................... <br /> Additional Footage Fee............. <br /> 04PSewer Tap Deposit .............. — <br /> S/,� TOTAL DEPOSIT...... <br /> Building Permit No. ti�4 <br /> Improvement Plan No. /J/Q <br /> Supplemental Conditions: /-14A)"iff <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with'all'provisions of thi'siperm&as well as'all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect,and to pay t&C rylts'actdi cost for ifemoval'and proper replacement of any item which <br /> does not meet above requirements. Failure to comply.wal[l/be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs;.or:darnagesiresulting from injuryttovpersons;'death of.person or damage to property <br /> occuring at the site of or as a result of work to be:_performed.lnder this permit..A:-certificate oUinsurance shall be submitted to the <br /> City Risk Manager prior to beginning constructiono:. Ili'A rA .E 't; <br /> PERMITTEE SHALL CONTACT UNDERGROUN69j' V'j6E•ALERT(1-800-842-2444)'TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of thispermi before signs g — No requirement of notifications and inspections. <br /> Signed: -- .— ---Phone 7 i.._(e <br /> tst—Permittee 2nd—File 3rd—Finance <br /> 4th—Utility/Street <br />