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CITY OF STOCKTON <br /> 65251 <br /> DEPARTMENT OF PUBLIC WORKS <br /> P;10 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> (cant s Name r �� Jfjate /� <br /> ner/Contractor /� <br /> dress 7� /21 ��f� �'i✓P_.f/e/c.�� Phonel4h} <br /> cation Ot Proposed work etc v/ APPROVED PUBLIC WORKS DIRECTOR <br /> � L r O Z <br /> OwnerlContractor Address By Date ! <br /> emoted Starting Date / Completion Hate G� / <br /> -� Permit Expiration Date <br /> ! (or We) hereby apply for an encroachment permit to carry out the following work <br /> LL <br /> 5-r�LY��S <br /> ^n > .. <br /> � r � V Y ✓ <br /> The above named app?,cant herepy requests permi63ion to <br /> PERMIT FEE g � <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> ALL tom► �, TOTAL DEPOSIT <br /> $ <br /> Building Permit No <br /> Improvement Pian No <br /> Suppiementaf Conditions <br /> �Sr;fc TNS 102 Lt lC <br /> ,,44L- t f��'SST2r�l ] ' o niIL-,k7 <br /> Show SMetCh above of rotor to drawing submitted tjoe^- o,\x-r Ajo LA e as JG C <br /> 2 LL , ~ '� ALV <br /> ORTANT Applicant hereby agrees to comply with all provisionsAJO <br /> of this pelt as wells a I apable City ordinances, resolutions, � <br /> tdards 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 /> XCity harmless against any and all losses costs,or damages resulting from Injury to persons,death of person or damage to property <br /> wring 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 /> Risk Manager prior to beginning construction <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-8o0 8 2444) TWO WORKING DAYS BEFORE BEGINNING <br /> IRK FOR LOCATION OF UNDERGROUND UTILITIES <br /> MITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> JFGCION <br /> eneral Provisions on reverse side of thispermit efore signing — Note quireme of notifications and inspections <br /> Signed � <br /> F <br /> ' C-1 Ptione <br /> 1st—Permdtae 2nd—File 3rd—Financ4Ih_Uhi+tyr$treet <br /> LLL • <br />