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CITY OF STOCKTON u <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N! 62670 <br /> f Applicant <br /> (Owner <br /> N Phone <br /> Addres Cu <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> I Location of Proposed work,etc. / <br /> By Date <br /> Ow"gr/Contractor Addre <br /> { <br /> Estimated Starting Date <br /> ''��'' LCompletion pore— � Permit Expiration Date <br /> I for We) hereby a ply for an encroachment permit to carry <br /> followingswork: <br /> The above named applicant hereby requests permission to PERMIT FEE .... . ............... .. ... . ... ... f <br /> Additional Footage Fee. - - <br /> Sewer Tap Deposit ._..... ...... ...... .. ......... <br /> TOTAL DEPOSIT <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> rPERMITEE SHAD.CALL 937-5411 <br /> 4 HOURS PRIOR M START 0f <br /> ORK FOR A CONTROL NUMBER <br /> AND <br /> TO SCHEDULE INSPECTION <br /> Shaw 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, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace• <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit, Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing. "Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 <br /> 944.8366 Signed: _Phone _ <br /> I r I F F,IAI l ^Li.937-8411 <br /> I " -4r V,R TO START OF <br /> Ist—Permittee 2nd--fde 3rd,--Finance 4th--Utility/Street n <br /> CONTROL N <br /> UMBER s <br /> AND <br /> ] SCHEDULE INSPECTION <br />