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CITY OF STOCKTON 65217 <br /> CA DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> pbcant <br /> Heil ntracto e <br /> ress `{ .\.�t 't���va 5..,4� �a Phone -116331IL-SLOT' <br /> ocation of Proposed Work etc APPROVED PUBLIC WORKS DIRECTOR <br /> net/Contractor Address _ju_erl�aiaC <br /> Bq__ � Oate— rc�� <br /> Estimated Starting Dale �� Ot Completion Date Permit Expiration Date <br /> If (or We) hereby apply for an encroachment permit to carry out the following work —_ <br /> ' 0 <br /> The above named applicant hereby requests permssopn to <br /> PERMIT FEE 5 <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT S <br /> L14 l � Building Permit No <br /> �1 Improvement Pian No <br /> Supplemental Conditions <br /> 1�6v�OQ�►Z er g�,e� � c u_5�cE <br /> Show sketch above or refer to drawing submitted ( Ci0i rn <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 /> 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 />,occunng <br /> Clty Risk Manager prior to beginning construction <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-82444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCH Q <br /> INSPECTION <br /> ad General Provisions on reverse side of this permit before signing — Note requirement of notification ions <br /> Phony <br /> 1st—Permohee 2nd—File 3rd—Finance 4th—()tdrtyl street <br />