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i <br /> 64073 <br /> CITY OF STCKTON <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 1 Applicant's Name lkX3�_l� Date — Q <br /> (Owner/ Contractor) �r 1 / <br /> Address 11605 XV - A%fthI A L A4 Phone G 5 (a p2E <br /> Location of Proposed Work, etc. 14 V OS L Ct E!k Abe . APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner/ Contractor Address any 405 u`F� �yrii b� ey � Date 151, Z5 ' 9(a <br /> Estimated Starting Date CPJ Z b r Q 6 Completion Date 0� jz �' (ff ^Permit Expiration Date s <br /> I (or We) phereby apply for an encroachment permit to carry out the following work : a nonce- Soi� _h <br /> � /' In <br /> do I2i'Gnthi 5'4rq r + ) oil 4e Fqt 11 ( 0Jotbb <br /> fill <br /> I <br /> The above named applicant hereby requests permission to - PERMIT FEE . . . . . . $ ) Z <br /> Additional Footage Fee . . . . . . . . . . . . . <br /> S�� n Sewer Tap Deposit . . . . . . . . . . . . . . . . <br /> l.-�•• TOTAL DEPOSIT . . .. . . . . . . $ Z <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> M41v`t'Cu -�� Ot`\'� 1J�1E pC <br /> iyT Pla.� 'Tl pg� . <br /> � 1 <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 . <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800 444) 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 permit before signing <br /> — Note requirement of notifications and inspections. <br /> Signed: {/{ '1_ - _ - _""_`_b./�/l(vt/ — _ _ - - Phone q <br /> 1s1—Permittee 2nd—File 3rd—Finance 4th—Ullllly/Street <br />