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1 6� � yo <br />' _ CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> 1 <br /> . APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant s Name r + Date <br /> [Owner/Contractor <br /> Address ✓r PhonC� - O, <br /> 1 r JS G APPROVED. PUBLIC WORKS OIFIECTOR <br /> Location of Proposed work, etc Cyl <br /> 1 <br /> fh <br /> owner/Contractor Address By Date <br /> Estimated Starting Date 1—y y4 Completion Date Permit E.piratton Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work T/J AnuAd-L,-&it r' <br /> ' 1 <br /> 1 In <br /> - <br /> 1 <br /> The above named applicant hereby requests permission to r <br /> PERMIT FEE $ <br /> 1 Additional Footage Fee <br /> Sewer Tap Deposit r� <br /> TOTAL DEPOSIT 5 14 <br /> 1 Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> 1 <br /> 1 <br /> 1 Shaw sketch above or refer to drawing submitted <br /> 1 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 /> 1 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 /> l I <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-�2444) TWO WORKING DAYS BEFORE BEGINNING <br /> 1 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 this permit before signing — No requirement of notifications and inspections <br /> Signed- Phon 7D �� <br /> 1 tst—Permittas 2nd—Fie 3rd—Fnance 4th—Utility/Street <br />