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• CITY OF STOCKTONDEPARTMENT OF <br /> • <br /> OA APPLICATION FOR ENCROACHMENTBLIC ON UBL CSRIGHT-OF-WAY 6569 <br /> 7 <br /> Applicant's Name l�Ciypr —g 4an I r Date 2 /3/00 <br /> (Owner/Contractor <br /> Address 3I t q C201d ,, 9 Dc r le 240 Pnone *-631- 1100 <br /> cityR,>, o State CA 96670 APPROVED: PUBLIC WORKS DIRECTOR <br /> P <br /> ''rr ` 1 ZiL <br /> Location of Proposed Work,etc. _ n �Fl.O St�/Ie6uCitk�noAf <br /> o4 G llf mi S� a rox 70r n rH o-F F Mtkier Ave Mr <br /> owner/Contractor Address �Q ��, a -'G-� <br /> 7 Date <br /> Estimating Staving Date �' G� Completion Data 1 I �- -� <br /> Permit Expiration Date <br /> I (or We) hereby apply for an a oachment permit to carry out the following work: <br /> `` N <br /> The above named applicant hereby requests permission to _ <br /> PERMITFEE..........................................$ <br /> Additional Footage Fee...........................$ <br /> vie, Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT.............$ <br /> d Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ')y�ee�i tie "Av-�bA 0� (Yk6rA'1'6 Cali) <br /> '_!`wy fit'v- cr� Ova eccilo`le ��pBVtc <br /> d <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 UNDERGROUNgUTILITIES. <br /> PERMITTEE SHALL CALL(209)937 Q414244HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. X010 <br /> Read General Provisions on reverse sideit ore signing - Note requirement of notifications and inspections. <br /> signed of s er (Da V IA pngne:9r.6—631 — !add <br /> 1st-Permiae, 2nd-File 3rd-Finance 4th-Utility/Street <br />