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T <br /> © CITY OF STOCKTON 6494 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name q,&JDIfcr .L V lt- Date — O U <br /> (Owner/Contr c <br /> Address r EC- 5 J,��Phone -` _1� <br /> Location <br /> l�nlC� APPROVED: PUBLIC WORKS DIRECTOR <br /> Lo{cn[at� ofProposed <br /> pose�d�Work,etc. l C f <br /> Owner/Contractor Address S I� B Date 8 <br /> Estimated Starting Date K JW 11-11I Oil Co pletion Date Permit Expiration Date ma--y, Z <br /> I (or le) hereby apply for an enncroach�ent permit t carr out the followin work : � O G� <br /> c� <br /> It <br /> tS k�`K3r ��t,JIFI� 1� <br /> The above named applicant hereby requests permission to- PERMIT FEE. .. $__ <br /> Additional Footage Fee _ <br /> Sewer Tap Deposit .. .. <br /> TOTAL DEPOSIT $ C �_- <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> N-WW-a., <br /> TvkE -Va.o.V=A_ L AS <br /> t�o -Tv'4c'-4 E►- �css s k� u Qom. g-DLY p <br /> zs 0*3-<,RMe- ��Q NCS �4f C 6�Z.8E <br /> OF TwiS 0<)Q-V-, <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 <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. 042- <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 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 it before <br /> signing — Note requirement of notifications and inspections. <br /> Signed 3✓\ /' ig_V 4 Phone if U _I L[ 5 <br /> Ist-Pe—ttee 2nd—File 3rd- F,nance 4Ih -Utility/Street <br />