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A=lllllllllllllllll <br />J2000 17:14 <br />r <br />209467111 <br />AGE STOCKTON <br />CITY OF STOCKTON <br />DEPARTMENT OF PUBLIC WORKS <br />APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br />Appiicant'e Name Date r 410b <br />(Owner/Contracto <br />Address A I&Z � iQ Phone�7 /lJ�/ f� <br />City state_ zip trema <br />PAGE 02 <br />to 13 <br />APPROVED: PUBLIC WORKS DIRECTOR <br />Loca1lon of Proposed Work, etc. <br />Owner/ contractor Address J Date <br />Estimating Starting Date ib Completion Date % `b ®rmtxpiration Date <br />I (or We) hereby apply for an enroachment permit to carry out the following work: <br />The above ramed aporcant hereby repeats oermisvon to - <br />Show =ketch ebo" or refer to drawing eubmltted <br />PERMIT FEE .......................................... $ <br />Additional Footage Fee ........................... $ <br />Sewer Tap Deposit ................................. <br />TOTAL DEPOSIT ............. $ <br />Building Permit No. <br />Improvement Plan No. <br />Supplemental Conditions: <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 the <br />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 City <br />Risk Manager prior to beginning construction. <br />PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br />WORK FOR LOCATION OF UNDERGROUgqN3��jD UTILITIES. <br />PERMITTEE SHALL CALL (209) 937$4 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.i`�/� phone:_.96 <br />/ <br />1 et-P6rmltte6 2nd -Filo ard-Finance 4th-UlilitylStreet <br />