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r <br /> Q CITY OF STOCKTON 64553 <br /> DEPARTMENT OF PUBLIC WORKS <br /> _ APPLICATION F7OR ENCROACHMENT ON PUALIC RIGHT-0F-WAY ' <br /> scants Name r4U0k t�llid 101— ( Date <br /> �f�/'- <br /> wnerIContractor) <br /> Address 707 AlF*Oiu1 pk, AMWt-IOWSCPhone 0-370-3 <br /> po q6L 1t�p1�'�Y�WIIlfL A 11L�' APPROVED PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work etc <br /> Owner/Contractor Address /w O fL' l� By' <br /> y Date <br /> Estimated Starting Date �/ �` Q 7 Completion Date 7 f-7 Permit Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work -7 AeorrZ'f6ree'7-r t` <br /> 100''W 1 jT&IIV w&,I-c- fN Sr fh +,•yetvK vw +r1-YJr.__s I C)e vrr j4VE <br /> ReX0Q3L= pC-z-izmcr snn - ls. <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE $ <br /> Abddional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT $ <br /> Budding Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Show sketch above or rebr 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-"2-2444) TWO WORKING DAYS BEFORE BEGINNINCe <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 SCHEDULE <br /> INSPECTION <br /> or <br /> General Provisions on reverse side of this permit before ning -- a requirement of notifications and Inspections <br /> Signed Signetl Phone <br /> 1st—Permittee 2nd—Fde 3rd—Finance 4th—Utilgy!Street <br />