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• • 65190 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> AD APPLICATION FOR ENCROACHM <br /> ENT ON PUBLIC RIGHT-OF-WAV <br /> n <br /> Aqppplpnre Namet^�Ar, , Did, <br /> (Ovmerl Can traCtG <br /> Addra{{.------�` ��jL— Pi10nY�Yro[2 <br /> r 4 G t APPROVED: PUBLIC WORKS DIRECTOR <br /> La w of Propoeed Work.etc �n r' /l+rY� <br /> 0x 0r/Cantreclor AW,ews _ 9y Daw <br /> grn <br /> E{ ated 9unlns Dete li C6ftia" n Dna Permit Expinawn Dau <br /> I (or We) hereby apply for an enirachment permit to terry out the following work: S11 S -fir Ad r <br /> Tn•atro.•mmW•PWIx•m n•r•ey r•qu•M PxnnlYbn ro PERMIT FEE.. ..... .. <br /> Additlonal 12o120 F.............. <br /> 9ewr Tp Deposit ................ <br /> TOTAL OEP09tT.. ...... <br /> Bullding Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> i <br /> ensu w¢n•Uw•w r•W m Ur•wbp•uamkrd <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 coat 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,Costa,or damages resulting from Injury to persona,death of person or damage to property <br /> occuring at the site of or as a result Of work to to performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SMALL CONTACT UNDERGROUND SERVICE ALERT(I.600-fte-2444)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SMALL CALL(209)997-641124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND 10 SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit/ before signing — NO requirement of notifications and Inspections. <br /> A32f%4300 <br /> L—Permiuse 1ne—ri• are—F'.vnc• en—lnllnyr6u••t <br /> OVI M SIQV08v W014 Ind 8£ 20 86-0£-Zi <br />