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r- <br /> 6521 7 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> I <br /> I W nl s 1 _ �,r tr�...a..,,.i•+•.t Ze a�l.st1�Z,.rDate t 7L l <br /> nerl�pnlrSlC1 - — '-� 9� --- <br /> ress_ Phone NO-TIZ-y,or <br /> �S- C <br /> '1�i4•t� - _ APPROVED. PUBLIC WORKS DIRECTOR <br /> Locetbn of ProOoseded worl� etc <br /> Unetl Contractor Address ��.a _ -- g Date <br /> Estimated Stkrtjng Date _11 -)-L- I,�gCamplelion Date _ F'errhtl Explralron Date6�� I <br /> (or We) hereby apply for an encroachment permit to carry out the following work <br /> C27 <br /> ,.,—�. ��ta <br /> colt. i <br /> rhe above named applitani Mereby mgmntC pgrmtbsSon 10 <br /> PERMIT Ftp �-� L <br /> ^`� Additional Fooiage Fee --_ -- - <br /> Sewer Tao oeposll <br /> � r 1JiV � Wt� TOTAL DEPOSIT s_ 2 � <br /> Building Permit No <br /> Improvement Plan No <br /> U5� C LIQ C Supplemental Conditions <br /> Liu. Wxe� "Cl� C.ubu+l'E. <br /> E.1 lC t t►•1 Q;7— -t'V1%1 ftL- <br /> Show siunch abm-9 or Wer M drawing submitted tO �� pry\ <br /> PORTANT 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 /> es not meet above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold <br /> e City harmless against any and ill 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 /> ity Risk Manager prior to beginning construction <br /> ERMITTEE SHALL CONTACT UNDERGROUNIJ SERVICE ALERT (1-800=8 X2444) TWO WORKING DAYS BEFORE BEGINNI <br /> VP <br /> ORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> fEFiMITTEE SHALL CALL(209)9J7.8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBERAND U <br /> SPECTION <br /> 4eadn General Provisions on reverse side of this permit before signing -.- Note requirement of notificatib nd inspections <br /> t . <br /> t,+grscd � S 1 E jL7 Pn+rle t I Z to�9g <br /> +sf -Psr+n11CC 2nd Fllc <br /> 7M—FinenCs At4—Ur+4iY 151 <br /> TOTAL P 02 <br />