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• 64764 <br /> © CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 1 <br /> ,r— �,, C� <br /> Applicant's Name S Date Sz'- <br /> (Owner/Contractor) 11 <br /> Address .Z]�1 ��C' �ST��" SPone <br /> Location of Proposed Work, etc. fT• �,=(� tr f"F I��rp<..- APPROVED: PUBLIC WORKS DIRECTOR <br /> '•��, S: /� 1 Jts,/�� I"�. 7,� 143-7 S - Ark `{• l <br /> Owner/Contractor Address A bz;Jf. B / ' Date_ z�-: <br /> Estimated Starting Date i S Completion Date 7/ Permit Expiration Date ti <br /> I (or We) hereby apply for an encroachment permit to carry out the following work :. �L i I �j .(..•cC;, <br /> i <br /> >, ti r c% 01 ! 5 r '/ L, f C�� 7�Z C`7l 5 5 —u ii <br /> j' z�tt <br /> JL4 4--iK1, b rGS �! tr t� en 4 V- Kms•�-l� iJl;�P-11 i <br /> L 11 ��-1T• l ar �l t�'�V �J� ` ✓�+�.tY�.>` � Ic�.#�1� a �� 1 '•\.�i <br /> kZ t—�Y '}T� � t_�1��V V "'ice ��l!-�l:\� ( -JI��. f�'L �t��r�... � �l� �+y.•I <br /> The above named applicant hereby requests permission to- PERMIT FEE. .... ... ...... .. .... $ <br /> Additional Footage Fee.. ... ....... <br /> Sewer Tap Deposit . ......... ..... <br /> ".::�-alk (.Cr-•t�i®t /y/v'7Z+� '�"� / � � s <br /> TOTAL DEPOSIT......... $ <br /> t Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> w� Mc <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800'bQ-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 permi beforXsiiAngNot7quirement of notifications and inspecttions. <br /> Signed: Phone1st—Permittee 2nd—Filer — nance 4th—Utility/Street <br />