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ALM., <br /> CITY ,OF STOCKTON <br /> DEPARTMENt' bi'PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WAY <br /> w r x N! 62304 <br /> IApplicaI L.L 1 N(a pate i <br /> lowner tractor) i iiisfw-k p2tct_s <br /> Location of proposed Work,etc. 7S t.'14 ^} APPROVED: DIRECTOR OF PUBLIC WORKS <br /> +er eontfactorAddrees_ _(Dal w, �YfpH*VC Q+bcwIV� A e 95031 Date' c <br /> Estimated Starting Dote ; S Completion Date Permit Expiration Date 3e <br /> I (or We) hereby apply for an encroachment permit to carry out tate following work: I N-5—FAt-L- 0,,J 15 S-5— <br /> 62ou N. wigriz /tn ,1 i Tt,2+N 6 <br /> 6 T — 0F- w <br /> The above named applicant hereby requests permission to- PERMIT FEE ...............................................: s + <br /> i <br /> Additionoi Footage Fee. <br /> Sewer Tap Deposit ................................... iI <br /> i <br /> TOTAL DEPOSIT $ <br /> Building Permit"No. <br /> Improvement Plan No. <br /> Supplement c IVE itions: <br /> Wallace-Kuhl Associates <br /> L <br /> 96(, <br /> pry �v) JUL L �i 1995 <br /> iS'JJ D,K AMS SLF <br /> JPC DFS EJFI DRG <br /> Show sketch above or"refer to drawing submitted CAR KM8 RLP C <br /> VLG DLG DVA <br /> A <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all.applicable City ordinances, t <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 an reverse side of this permit before signing. .*Note requirement of notifications and Inspectlons. <br /> Permit Engineer/Inspector <br /> 944-8250 �. <br /> 944.8366 Signed: --• Phone ib 7"2--l4- <br /> .. <br /> i <br /> 1st—Permittee 2nd--*ile 3rd—irnpnce �ih--UfiFify/Strcat <br />