Laserfiche WebLink
CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS' <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-MWAY <br /> Applicant's Narne /�✓ L�• _ Dat 6 (JG ,i `:°^x'- 5 65 `t 1 <br /> (owner/eontroct ) <br /> Addres Phone <br /> 4APOVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc .lz O ter,_ s ;�Owner/contractor Address Date <br /> Estimated Starting Date A4 Completion Date Permit Expiration Date <br /> I for We) hereby apply for an encroachment permit to carry out the following work: <br /> r�-Al <br /> The above named applicant hereby requests permission to- PERMIT FEE <br /> f <br /> Additional Footage Fee,.... ..... ................. <br /> Sewer Tap Deposit .................................... C ' <br /> TOTAL DEPOSIT S y` <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> tMPORTANT: Applicaht hereby agrees to comply with all provisions of this permit as well as all 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 /> Read General Provisions on reverse side of this permit before signing. "Note requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944.8492 2/ <br /> 944.8366 Phone <br /> Ist--Permittee 2nd--file 3rd—Finance 4th—Utdity/Street <br />