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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61701 <br /> Applicant's Nome <br /> (Owner/Con��ttoctorl <br /> Addres "a��r� �H Phone <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed work,etc.J <br /> o.,re./cpar.aetor9tddress �/7fd 4 Dafe_:�e�r���' / '_ <br /> � 2Com I t " b to P 't Expiration Dat <br /> E t d Storting Dot._ 5r I <br /> for We) hereby apply for an encroachment permit to carry out the following war <br /> The above named applicant hereby requests permission to - PERMIT FEE ............................................. $ <br /> Additional Footage Pee._.. .... _. .........._. <br /> Sewer Top Deposit ................................... <br /> TOTAL DEPOSIT ... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: . <br /> MAY 0 y-6 1992 <br /> Show sketch above or refer to drawing submitted EWMNMEN AL HESLIH <br /> PERMIT/SERVICES <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requiremenfs. failure to comply will because for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse aide of this permit before sigrequlrbment of notlficatione and Inspections. <br /> Permit EngineerlInspector <br /> 944-8250 PhoneS <br /> �\V �p�L <br /> 944-8366 Signed: <br /> Ift--0vmittee 2nd—File 3rd—Finance sth—Utility/Street <br /> /t�a <br /> 2 <br />