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1 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 60085 <br /> ppplaant-ti Naa+° APPROVED: DIRECTOR OF PUBLIC WORKS <br /> t6+.ner/Conlracrni _._ Ptione-.'----._.•---•--__ <br /> Address sem . —yY�----- <br /> ud V1ork,etc <br /> Locnl;on of Propo <br /> _ <br /> p.mer/ContrM'tor AdNess.— Ca—��f--_�..Pe'm t E. Dnrr—._ <br /> ;p _Co,er,on Dale.--�� =�_�� --' • �/_..' <br /> Esrimaredout the <br /> cro <br /> I for on enachment permit to carry �1�l�lvlor� -- <br /> 1 (or Wel hereby apply � <br /> -- -------- <br /> PEPhrIT FEE 5— - <br /> 1he above Homed oppj,,0ni hereby requests Perm't"on to ^� <br /> Additmnfonto9e fee <br /> Sewer Top Deport - /p <br /> TOTAL DEPO$11 .... .............. S—�-i—• <br /> Building Permit NO- <br /> lmi 3vement Plan No. - ---—'-- <br /> Supplemental Conditions <br /> 1 <br /> Show sketch above or refer to drowlna s,bm fled <br /> Itcahie City ordinances, <br /> I with a!I provisions of thls permit as +Areli as all app a e1 frploce <br /> e ificaEions currently `n effe[S, and to PaY to Ci•,y its aUufll cosi for rEmava' <br /> and p� p <br /> IMPURTA►JT: Appli[ant hereby agrees to come Y <br /> resolutions, standards and sP and all losses, costs, Lu damages resulting ftorn in;ury to <br /> an item which does not mee! above requiream ainst any a to comply writ costs, <br /> cause for revot'aiioC'r`a n nc fuck r this <br /> ment of Y and hold the City harmless g <br /> [ant agrees to indemnify occurring al the site of or as a restilt of war o P <br /> persons, death of person or damage taproperty a Itot t upon request, <br /> permit, Certificate of insurance will be presented byefore signing. 'Note requirement of notN!cLttions and inspections, <br /> Read General Provis,,ons an reverse side of this permit <br /> Permit Engineerlinspector <br /> F - <br /> $pnad <br /> 944.8356 r /6-STo <br /> 3,y—=nan-c ath— t E.r},'ie ret <br /> - Id^rPermlTtre :^0-r;F0r - <br />