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fm"A CITY OF STOCKTON 64624 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 9 1 ) <br /> Appitcant s Name 5 E GO Sig 34-1c,ita ni+a 1 ? � Date ,,kill 4 <br /> (Owner/Contractor <br /> Address 2P7hone 916 3(4-18$ <br /> Location of Proposed work etc Df.�4►-Oy G WtAr APPROVED PUBLIC WORKS DIRECTOR <br /> u t <br /> Owner/Contractor Address ����__ G By Date k 1 <br /> Estimated Starting Date —No 17 /7 g Complet on Date VO 1�l df Permit Exp ration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work Destroy (o G�ovha(W�der <br /> i ri uwf 1�cc��t-r.I �H P„bl.c. 1Zi IJ-off- �i1at 1 Weds will ht ressu.c 5 rovko� fb <br /> ur akaA�C &,W-11 box iivr V er 5 Gi a'F WeR Will 6e ryewtbvtl <br /> side tvt11 bio+, >L� back fo rRdle W+e!/1 arc Jvcti� !'h rajVe.( -• <br /> rip As 10-1 k o r Lc+z rc'Nc pre—se—ft. - s_ Qp r K- s"ll.( 4x pc <br /> The above named applicant hereby requests permission to PERMIT FEE $ 2� <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> IDTOTAL DEPOSIT $ <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <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 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 04,L <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-8004.2-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections <br /> Signed Vl�, PhonL(31 1709— /U eo <br /> tsl—Permtlee 2nd--File did—Rnance 4th—Uhhtyf Street <br />