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CITY OF STOCKTON <br /> SSU <br /> DEPARTMENT OF PUBLIC WORKS Ago L= <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY efa w <br /> > <br /> 1 <br /> ,�77 t <br /> Applicant' 13JWt�;(, �4F1�t.�'+7tC - Date O <br /> (Owner/ nt _ Lr, <br /> Address T nT /Lt P h o n e rtlf,).:;c V-le 9.59.`5 <br /> Location of Proposed Work, etc. -Ly t- �, APPROVED: PUBLIC WORKS IWEC, I _G <br /> !,Z I15 7 1k -7- i. 40 <br /> Owner Contractor Address ST •'aA1141L.,$via+%-iGs".u;,► (A By N Date etI <br /> l'sMs <br /> Estimated Starting Dates`24 rCrr_ Compfetion Date Permit Expiration Date U <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : 1 HSi�al.LATt itJ OF D+,)£- <br /> w..9 j <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE. . .... . . . ..... .... .. $ lv7 <br /> Additional Footage Fee. . . ._. ... . .. <br /> Sewer Tap Deposit ... . . .. . . ..... . <br /> TOTAL DEPOSIT .. .... . $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> I) No 1 a+ie, CI O W vc�s pay mitttd . <br /> Z) Fe.YVAi tt?Z 5h 41 re NLOve, A^of- <br /> 1 reftaw A^U 4dyma6ed f7?A4WM k-- <br /> n l <br /> arestore, if 1v it5 ierbiK4d <br /> AcH�i� S + aLJ date., <br /> 1 Show 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, 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 (1-800-82 444) TWO WORKING DAYS BEFORE BEGINNING <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 /> Read General Provisions on reverse side of this perm i efore sig 'n — ate r quirem of notificationsQandd�i/n�sp/eQcttiions. <br /> Signed _ -- _ _ —,--- .-- - .—_ Phone �g) ✓W�f_x+98. <br />' lv—Permittee 2nd—File 3rd--Finance 4th UaiiitylStreet <br />