Laserfiche WebLink
© CITY OF STOCKTON 64953 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name yJ t✓f n.1�� -+— Date /5 f <br /> (Owner/Contractor) F. Nrr+�C _ I��� <br /> Address 1 I J Phone <br /> r ii� I' D / APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed work,etc. ft k It�fZ tk (C <br /> c <br /> Owner/Contractor Address <br /> j By Date <br /> Estimated Starting Date — r Completion Date Permit Expiration Date <br /> c— <br /> I (or We) reby appl f r an encroac ent permit to carry ut the following work : Sit I ) <br /> 1 <br /> b VV) <br /> t <br /> d1A&I <br /> The above named applicant hereby requests permission to- <br /> I 1 AWAIrl <br /> PERMIT FEE..................... $ C/;}{A' �,o.JCAPdAdditional Footage Fee............v1`1�lAWSewer Tap Deposit ...... ......... <br /> TOTAL DEPOSIT......... $ T <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> IC FEA Z L0" Of-- 7V-` C- CPC--J <br /> Lx� Q_V_ Sri k\ he— A <br /> C) W dm co 3 co <br /> Show sketch above or refer to drawing submitted V--�t - <br /> UP (-e-tcIL. TC •T)A- L"CP T cF t,xe.iC <br /> IMPORTANT Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, L <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 %Ayr'"' <br /> City Risk Manager prior to beginning construction. ern <br /> (04-2- <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-'84,2-2444) 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 perm' before signingf— Note requirement of notifications and inspections. <br /> Signed Phone I <br /> I st—Permittee 2nd—Fite 3rd—Finance alh—Utility I Street <br />