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f <br /> 63955 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> AlaAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name + t Date <br /> (owner l Contractor) <br /> Address £ Phone 2 -I- 1.- 2Y <br /> 2 4 5 � - &(z , <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed work,etc. � <br /> Owner!Contractor Address b Q 9y Date <br /> Estimated Starting Date "Z —y to Completion Date 2—zLn `Permit Expiration Dale t ' <br /> (or We) hereby apply for an encroachment permit to carry out the following work <br /> The above named applicant hereby requests permission to- PERMIT FEE............ <br /> Additional Footage Fee............. _ <br /> Sewer Tap Deposit ......... ....... <br /> TOTAL DEPOSIT......... <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch aSove or refer to draw�.,a<_ubmined <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. &4-.9-- <br /> PERMITTEE <br /> o4'ZPERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800.842444) 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 p rmit before signing — Note requirement of notifications and inspections. <br /> Phone-----.�w.__.._.----•- <br /> tsi--Permatee Intl--file 3rd—Finance 41h—Utility/Slreet - <br />