Laserfiche WebLink
Q CITY OF STOCKTON 64 4 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name &1441c I AC- Date Q 3 <br /> (Ownerl tra to <br /> Address_ OZ i`I , Sup 2 Z(Q Phone gI -131-13 o2 <br /> Location of Proposed Work etc F_r4 i neC Arve APPROVED PUBLIC WORKS DIRECTOR <br /> a 1 niw a k <br /> Owner lcontractor Address 0. VC► yDate_" <br /> Estimated Starting Date !d 32 Completion Date + I rkf— <br /> mlt Expiration Date - <br /> 1 (or We) h eby apply for an t~ncroachtttent it to arry put the folio mg work f sS <br /> �dc <br /> (02-70A - ce^. 3 v+u--, ber <br /> The above named applicant hereby requests permission to PERMIT FEE $ �� <br /> L L <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> V` TOTAL DEPOSIT $ <br /> 1 <br /> U Building Permit No <br /> 4 Improvement Plan No <br /> t <br /> S�uplementall onditionl. <br /> klt to C Ave <br /> -2)- <br /> Shuw 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 (94 <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-8007422444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGgggR��OppUND UTILITIES <br /> PERMITTEE SHALL CALL(209)937-8444 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION <br /> Read General Provisions on reverse side of this per "fore i — Note requirement of notifications//and inspections <br /> Signed Phone cFl 6 31 30D <br /> 1st—Permittee 2nd—File .ird—Finance 4th—utdPly IStreet <br />