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64353 <br /> Q CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name Dal Date <br /> (Owner/Coniracto I <br /> Address_ gyp t � }�,Q a A) e4A edd Phone 10lel-13G <br /> (5&-bov* APPROVED PUBLIC WORKS DIRECTOR <br /> Location of Proposed work etc <br /> 37 _ f /D� ,9Y i an/ <br /> Owner/Contractor Address By Date 4 -7 �- <br /> Estimated Starting Date +���S� Completion Date Permit Expiration Date <br /> (or We) hereby apply for an encroachment permit to carry out the following work <br /> X-r e4l Ch1-S N- <br /> saFN.�Lx o ,F,zvia. <br /> '1 <br /> r <br /> I <br /> The above named applicant hereby requests permission to PERMIT FEE <br /> 3 <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> i <br /> /�}7;rWd /'��iLLe�. 3 TOTAL DEPOSIT $�'Z <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> 1 <br /> Show sketch ibove or refer to driwing submitted 1 <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 2 <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800 -2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> � <br /> ERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> SPECTION <br /> I <br /> Read General Provisions on reverse side of this permit <br /> ��before <br /> sisigniinngg/— Note requirement of notifications and/inspections <br /> Signed �TFT.�GC l�/J �yQ -- ---- Phone&4) <br /> IM—Permillee 2nd--file drd—r inAnce aih--Utdrtyl Street <br />