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X34 : <br />�. CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> i <br /> Applicant's Namo �A'���a�l moi.'4.ur• �irsc. /.!thy. Date <br /> (OwnerlC r) <br /> Address nntra)va n� L .Q/' is St� �Phond,!//�t� <br /> -�4�3i <br /> Location of Proposed Work, etc. " �5` �ii7 ��%/irYv��1 `�il'�E APPROVED: PUBLIC WORKS DIRECTOR <br /> Owne Co Address !;"- AS g t�� <br /> cy- n y Date cJ Z .-/�-�Q_ <br /> Estimated Starting Date n.� f y Completion Date X Permit Expiration Date <br /> I (or We) hereby apply for an encroachmtt rmit to carry out the following work : 1nG13 • 4 <br /> u <br /> x '11 .n� •h.- , C?/1� : C j' �ai,/' = 3 <br /> �`"�CI Cc�•:✓'-:.Pt��cr.� f; cr�c}':�f/,c�+� r'r.��rlF� ��,�1� <br /> The above named applicant hereby requests permission to- PERMIT FEE.. .. . ._ $ <br /> Additional Footage Fee_ ... .. .. ~ <br /> ff Sewer Tap Deposit . ... .. ....... <br /> TOTAL DEPOSIT __... .... $ <br /> Building Permit No. <br /> r Improvement Plan No. ^J <br /> Supplemental Conditions: <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 <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-�z2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Bead General Provisions on reverse side of this permi before signing — No ree{uirement of notifications and inspections. <br /> Signed', _ - -- _ Phone 7/-(e <br /> 151—Permittee 2nd—File 3rd—Finance 41h—Utility l Street <br />