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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> M APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 62670 <br /> Applicant's Nor" .Date (10 :2-,- <br /> (Owner/ConJr7 /-,'. / �[ Phdne —&u— <br /> Address-f�/ !/" LCT <br /> APPROVED: DIRECTOR Of PUBLIC WORKS <br /> Location of Proposed Work. <br /> 7-2 <br /> 40a� <br /> Owner/contractor Address/� _ By Dare <br /> Estimated Starting Date l f— f _—Completion Dote__L—/_.—/_.J Permit Expiration Date___. ~( <br /> I (or We) hereby a ply for an encroachment permit to carry out the following work: <br /> The above named applicant hereby requests permission to - PERMIT FEE . _.. .. ... $ <br /> Additionol Footoge Fee. . <br /> Sewer Tap Deposit ....... ..... ... ... ..... ... <br /> TOTAL DEPOSIT ....... ............. S <br /> Building Permit No. <br /> Improvement Pian No. <br /> Supplemental Conditions: <br /> PERMITEE SHAD.CALL 937-9411 <br /> 24 HOURS PRIOR TO START OF <br /> WORT(FOR A CONTROL NUMBER <br /> AND <br /> TO SCHEDULE INSPECTION <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 off 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 /> Head General Provisions on reverse side of this permit before signMg. "Mote requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 —02 <br /> 944.8368 Signed: Phone <br /> I i F ;'161 t C^•LI. 937-8411 <br /> # " <br /> Isr—Fermitlre 2nd.--file 3,d^-Frnan[e 41h,.UtrhfY/Srreef .3r!V.it TO START OF <br /> i r 1 ;9 1 CONTROL NUMBER <br /> AND <br /> `r) SCHEDULE INSPECTION <br />